Neuro Examination & Localisation
Upper vs lower motor neuroneImportanttap to open ▾
UMN: increased tone, brisk reflexes, up-going plantars, no wasting/fasciculation, 'pyramidal' weakness. LMN: reduced tone, absent reflexes, wasting, fasciculation.
UMN signs: ↑tone (spasticity), hyperreflexia, extensor plantar (Babinski), minimal wasting.
LMN signs: ↓tone, hyporeflexia/areflexia, wasting, fasciculation.
MND: Uniquely mixes UMN + LMN signs with preserved sensation.
A patient has brisk reflexes, increased tone and up-going plantars in the legs. This pattern indicates what?
- ALower motor neurone lesion
- BUpper motor neurone lesion
- CPeripheral neuropathy
- DMyopathy
- ENormal
Correct: B — Upper motor neurone lesion
Why: Increased tone, hyperreflexia and extensor plantars are upper motor neurone signs.
Options:- LMN gives ↓tone/absent reflexes.
- (correct)
- Would give sensory loss.
- Weakness without these reflex changes.
- Abnormal.
Cranial nervesImportanttap to open ▾
12 cranial nerves; common exam pointers: CN III palsy (down-and-out, ptosis, blown pupil — surgical vs medical), CN VII (facial — UMN spares forehead, LMN doesn't), CN V (trigeminal sensory + corneal reflex).
CN III: Ptosis, 'down and out' eye; fixed dilated pupil = compressive (aneurysm/uncal) — surgical.
CN VII: UMN lesion spares the forehead (stroke); LMN affects it (Bell’s).
CN VIII: Vestibular schwannoma — unilateral hearing loss + tinnitus.
A patient has a facial droop that spares the forehead. Where is the lesion?
- ALower motor neurone (facial nerve)
- BUpper motor neurone (e.g. stroke)
- CNeuromuscular junction
- DMuscle
- ESkin
Correct: B — Upper motor neurone (e.g. stroke)
Why: Forehead sparing indicates an upper motor neurone facial lesion (the forehead has bilateral cortical innervation); Bell’s palsy (LMN) involves the forehead.
Options:- LMN involves the forehead.
- (correct)
- Different pattern.
- Different pattern.
- Not neurological.
DermatomesRare · recognise
Key landmarks: C2 back of skull, C6 thumb, C7 middle finger, C8 little finger, T4 nipples, T10 umbilicus, L1 groin, L4 knee, L5 big toe, S1 little toe/sole.
MyotomesRare · recognise
C5 shoulder abduction, C6 elbow flexion, C7 elbow extension, L2/3 hip flexion, L3/4 knee extension, L4 ankle dorsiflexion, L5 big-toe extension, S1 plantarflexion.
MRC power scaleRare · recognise
0 none · 1 flicker · 2 movement with gravity eliminated · 3 against gravity · 4 against resistance · 5 normal.
Extensor plantarsRare · recognise
Up-going great toe (Babinski) = UMN lesion. Combined with absent ankle jerks → think subacute combined degeneration, MND, or a mixed lesion.
Cerebellar diseaseImportanttap to open ▾
DANISH: Dysdiadochokinesia, Ataxia, Nystagmus, Intention tremor, Slurred/scanning speech, Hypotonia/heel-shin. Ipsilateral signs. Causes: stroke, MS, alcohol, tumour, paraneoplastic.
Signs (DANISH): Dysdiadochokinesia, Ataxia (broad-based gait), Nystagmus, Intention tremor, Scanning speech, Heel-shin incoordination.
Localisation: Signs are ipsilateral to the lesion.
Causes: Stroke (PICA), MS, alcohol, posterior fossa tumour, paraneoplastic.
A patient has a broad-based gait, intention tremor, past-pointing and scanning speech. Where is the lesion?
- ABasal ganglia
- BCerebellum
- CFrontal lobe
- DPeripheral nerve
- ESpinal cord
Correct: B — Cerebellum
Why: Ataxia with intention tremor, past-pointing and scanning speech localises to the cerebellum (ipsilateral signs).
Options:- Gives parkinsonism.
- (correct)
- Different signs.
- Sensory/LMN.
- Different pattern.
Headache & Facial Pain
MigraineCoretap to open ▾
Recurrent, often unilateral throbbing headache ± aura, photo/phonophobia, nausea; hours to 3 days. Acute: triptan + NSAID/paracetamol. Prophylaxis: propranolol (avoid in asthma) or topiramate (teratogenic). Aura + COC contraindicated.
Diagnosis: ≥5 attacks, 4–72 h, unilateral/pulsating, moderate–severe, aggravated by activity, with nausea or photo/phonophobia.
Acute: Triptan + NSAID/paracetamol (± antiemetic).
Prophylaxis: Propranolol or topiramate; riboflavin 400 mg; amitriptyline.
Hormonal: Migraine with aura → combined pill contraindicated (stroke risk).
A 30-year-old woman with migraine WITH aura requests contraception. Which is contraindicated?
- AProgestogen-only pill
- BCopper IUD
- CCombined oral contraceptive pill
- DImplant
- EDepot
Correct: C — Combined oral contraceptive pill
Why: Migraine with aura is UKMEC 4 for combined hormonal contraception due to ischaemic stroke risk.
Options:- Safe.
- Safe.
- (correct)
- Safe.
- Acceptable.
Tension-type headacheCoretap to open ▾
Bilateral, band-like, non-pulsatile, no nausea, not aggravated by activity. Acute: simple analgesia (paracetamol/NSAID), no opioids. Prophylaxis (chronic): consider amitriptyline / acupuncture.
Features: Bilateral pressing/tightening; mild–moderate; no vomiting; normal exam.
Acute: Aspirin/paracetamol/NSAID; avoid opioids.
Chronic: Amitriptyline or a course of acupuncture.
A 25-year-old has daily bilateral band-like headaches with no nausea and a normal exam. First-line acute treatment?
- ASumatriptan
- BSimple analgesia (paracetamol or NSAID)
- CCodeine
- DAmitriptyline
- ETopiramate
Correct: B — Simple analgesia (paracetamol or NSAID)
Why: Tension-type headache is treated acutely with simple analgesia; opioids are avoided and triptans are for migraine.
Options:- For migraine.
- (correct)
- Opioids not advised.
- Preventive, not acute.
- Migraine preventive.
Cluster headacheImportanttap to open ▾
Strictly unilateral, severe periorbital pain, 15–180 min, in bouts, with autonomic features (lacrimation, nasal congestion, ptosis) and restlessness. Acute: high-flow oxygen + SC/nasal sumatriptan. Prophylaxis: verapamil.
Features: Unilateral orbital pain, 15–180 min, several/day in clusters, autonomic features, agitation.
Acute: 100% oxygen + subcutaneous/nasal sumatriptan.
Prevention: Verapamil.
A 38-year-old man has bouts of severe unilateral eye pain with a watering red eye, several times a day. Acute treatment?
- AOral paracetamol
- BHigh-flow oxygen + SC sumatriptan
- COral codeine
- DAmitriptyline
- EVerapamil
Correct: B — High-flow oxygen + SC sumatriptan
Why: Cluster headache responds acutely to high-flow oxygen and a fast-acting triptan; verapamil is preventive.
Options:- Ineffective.
- (correct)
- Ineffective.
- Not acute.
- Preventive.
Medication-overuse headacheImportanttap to open ▾
Chronic daily headache from frequent acute analgesic use (especially opioids/triptans ≥10 days/month, or simple analgesics ≥15 days/month). Management is withdrawal of the overused drug.
Cause: Regular acute painkiller use paradoxically causes daily headache.
Manage: Abrupt withdrawal (simple analgesics/triptans) — warn of transient worsening; taper opioids.
Prevent: Limit acute treatment days per month.
A patient takes codeine most days for a daily headache. What is the likely diagnosis and management?
- AMigraine — start a triptan
- BMedication-overuse headache — withdraw the analgesic
- CCluster — give oxygen
- DTension — increase codeine
- ETumour — image
Correct: B — Medication-overuse headache — withdraw the analgesic
Why: Frequent analgesic use (especially opioids) causes medication-overuse headache; the treatment is withdrawal of the overused drug.
Options:- More drug worsens it.
- (correct)
- Wrong diagnosis.
- Escalating worsens it.
- Not first thought here.
Temporal arteritis (giant cell arteritis)Importanttap to open ▾
New temporal headache + scalp tenderness + jaw claudication in >50s; risk of irreversible visual loss. Raised ESR/CRP; temporal artery biopsy. Start high-dose steroids immediately (60 mg if visual symptoms) — do not wait for biopsy.
Features: Unilateral temporal headache, scalp tenderness, jaw claudication, ±visual loss; often with PMR.
Investigate: ESR/CRP raised; temporal artery biopsy (skip lesions).
Treat now: Prednisolone 40–60 mg immediately (60 mg + same-day ophthalmology if visual symptoms).
A 72-year-old has a new temporal headache, jaw claudication and transient visual blurring. Immediate management?
- ASumatriptan
- BHigh-dose prednisolone immediately + same-day ophthalmology
- CCarbamazepine
- DAmitriptyline
- EWait for biopsy
Correct: B — High-dose prednisolone immediately + same-day ophthalmology
Why: Suspected GCA with visual symptoms is a sight-threatening emergency — give high-dose steroids at once; investigations must not delay treatment.
Options:- For migraine.
- (correct)
- For trigeminal neuralgia.
- Not indicated.
- Delay risks blindness.
Trigeminal neuralgiaImportanttap to open ▾
Brief, severe, electric-shock facial pain in a trigeminal division, triggered by touch/chewing. First-line carbamazepine. Refer if red flags (young, sensory loss, bilateral → ?MS) or refractory.
Features: Paroxysmal unilateral stabbing facial pain, trigger zones.
First-line: Carbamazepine.
Refer: Atypical features, under-40, bilateral, or poor control.
A 60-year-old has brief severe stabbing right-cheek pain triggered by brushing teeth. First-line drug?
- AAmitriptyline
- BCarbamazepine
- CGabapentin
- DSumatriptan
- EParacetamol
Correct: B — Carbamazepine
Why: Trigeminal neuralgia is treated first-line with carbamazepine.
Options:- Not first-line.
- (correct)
- Second-line option.
- For migraine.
- Ineffective.
Stroke, Bleeds & Raised ICP
Stroke: assessment & acute managementCoretap to open ▾
FAST-positive/ongoing deficit → emergency admission. Urgent CT to exclude bleed; if ischaemic and ≤4.5 h → thrombolysis; large-vessel occlusion 6–24 h → thrombectomy; then aspirin 300 mg for 2 weeks.
Recognise: FAST; sudden focal deficit.
Image: Urgent non-contrast CT to exclude haemorrhage.
Reperfuse: Alteplase/tenecteplase ≤4.5 h; thrombectomy for large-vessel occlusion 6–24 h.
Then: Aspirin 300 mg × 2 weeks → clopidogrel; high-intensity statin; anticoagulate if AF.
A patient has FAST-positive symptoms present for 1 hour. What is the priority?
- ATIA clinic in 24 h
- BEmergency admission for CT and reperfusion
- CAspirin and review
- DRoutine referral
- EReassure
Correct: B — Emergency admission for CT and reperfusion
Why: An ongoing focal deficit is a suspected stroke requiring emergency admission for imaging and possible thrombolysis/thrombectomy.
Options:- That’s for resolved TIA.
- (correct)
- Under-treats.
- Too slow.
- Unsafe.
TIACoretap to open ▾
Transient focal deficit that fully resolves. Give aspirin 300 mg immediately and refer to be seen by a specialist within 24 hours. ABCD2 no longer used to defer assessment.
Action: Aspirin 300 mg now; specialist assessment within 24 hours.
Then: Clopidogrel + statin; carotid imaging (endarterectomy if >70% symptomatic stenosis); manage AF.
Amaurosis fugax: Transient monocular visual loss = TIA equivalent.
A patient had 20 minutes of unilateral arm weakness yesterday, now fully resolved. Best management?
- AReassure
- BAspirin 300 mg and specialist review within 24 hours
- CWarfarin now
- DRoutine referral
- ECT then discharge
Correct: B — Aspirin 300 mg and specialist review within 24 hours
Why: A suspected TIA needs immediate aspirin 300 mg and specialist assessment within 24 hours.
Options:- Needs assessment.
- (correct)
- Only if AF confirmed.
- Too slow.
- Insufficient.
Subarachnoid haemorrhageImportanttap to open ▾
Sudden 'worst-ever' thunderclap headache ± neck stiffness, photophobia, reduced consciousness. Urgent CT; if negative and still suspected, lumbar puncture ≥12 h (xanthochromia). Usually berry aneurysm; neurosurgical referral.
Features: Thunderclap occipital headache peaking in seconds; meningism; may have focal signs.
Investigate: Immediate CT; LP at ≥12 h for xanthochromia if CT negative.
Manage: Neurosurgery; nimodipine to reduce vasospasm.
A 50-year-old has a sudden 'worst-ever' occipital headache peaking within seconds, with neck stiffness. What must be excluded first?
- AMigraine
- BSubarachnoid haemorrhage
- CTension headache
- DCluster headache
- ESinusitis
Correct: B — Subarachnoid haemorrhage
Why: A thunderclap headache is subarachnoid haemorrhage until proven otherwise — urgent CT, then LP if needed.
Options:- Not thunderclap.
- (correct)
- Not sudden/severe.
- Different pattern.
- Different.
Subdural haemorrhageImportanttap to open ▾
Venous bleed (bridging veins); elderly/alcoholic/anticoagulated after (often minor) head injury; fluctuating consciousness/confusion over days–weeks. CT shows crescent-shaped collection crossing suture lines.
Who: Elderly, alcohol excess, anticoagulated; may be a trivial injury.
Course: Insidious — headache, confusion, fluctuating GCS over days to weeks.
CT: Crescentic (concave) collection, crosses sutures. Refer neurosurgery.
An 82-year-old on warfarin becomes increasingly drowsy and confused two weeks after a fall. What is the most likely diagnosis?
- AExtradural haemorrhage
- BSubdural haemorrhage
- CMigraine
- DDelirium tremens
- ETIA
Correct: B — Subdural haemorrhage
Why: A subdural haemorrhage is likely — elderly, anticoagulated, insidious decline after a fall; CT shows a crescentic collection.
Options:- Extradural is acute/lucid interval.
- (correct)
- No trauma link.
- Different context.
- Transient, not progressive.
Raised intracranial pressureImportanttap to open ▾
Headache worse on waking/lying/straining, vomiting, papilloedema, reduced consciousness, focal signs. Cushing's response (hypertension + bradycardia) is late. Urgent imaging; avoid LP if mass suspected.
Features: Morning/positional headache, vomiting, papilloedema, visual obscurations, falling GCS.
Cushing’s reflex: Late: hypertension + bradycardia + irregular breathing.
Action: Urgent CT/MRI; neurosurgery; do NOT LP if a mass lesion is suspected.
A patient has headaches worse in the morning and on coughing, with vomiting and papilloedema. What do these features suggest?
- AMigraine
- BRaised intracranial pressure
- CTension headache
- DCluster headache
- ESinusitis
Correct: B — Raised intracranial pressure
Why: Positional/morning headache with vomiting and papilloedema indicates raised intracranial pressure — image urgently.
Options:- Not positional/papilloedema.
- (correct)
- No papilloedema.
- Different.
- Different.
Head injury: NICE assessmentImportanttap to open ▾
CT head within 1 hour if: GCS <13 on arrival (or <15 at 2 h), suspected open/depressed/basal skull fracture, post-traumatic seizure, focal deficit, or >1 vomit. On anticoagulants → CT within 8 hours.
CT within 1 h: GCS <13 initially or <15 at 2 h; focal deficit; seizure; suspected skull fracture; >1 episode of vomiting.
Anticoagulated: CT head within 8 hours even without other features.
Safety-net: Written head-injury advice on discharge.
An adult on a DOAC had a head injury with no other concerning features. What does NICE advise?
- ANo imaging
- BCT head within 8 hours
- CCT only if symptomatic
- DMRI
- EDischarge with advice only
Correct: B — CT head within 8 hours
Why: Anticoagulation alone warrants a CT head within 8 hours after head injury, even without other risk features.
Options:- Anticoagulation mandates CT.
- (correct)
- Anticoagulation is enough.
- CT is the modality.
- Imaging required.
CNS cancerRare · recognise
Primary (glioma, meningioma) or metastases (lung, breast, melanoma). Progressive focal deficit, seizures, raised-ICP headache, personality change. MRI; refer neuro-oncology; dexamethasone for oedema.
Movement, Weakness & Neuromuscular
ParkinsonismCoretap to open ▾
Bradykinesia + rigidity + resting (pill-rolling) tremor. Idiopathic Parkinson's: asymmetric, levodopa-responsive. Refer untreated. Drug-induced parkinsonism (antipsychotics, metoclopramide) is symmetric. Manage by QoL: levodopa if QoL affected.
Triad: Bradykinesia, rigidity, resting tremor (asymmetric in idiopathic PD).
Mimics: Drug-induced (dopamine blockers), vascular, Parkinson-plus (PSP, MSA).
Treat: Levodopa if QoL affected; dopamine agonist/MAO-B if not; avoid abrupt withdrawal; avoid metoclopramide.
A 70-year-old has an asymmetric resting tremor, bradykinesia and rigidity affecting daily life. Best initial drug?
- ARopinirole
- BLevodopa
- CMetoclopramide
- DHaloperidol
- EAmantadine
Correct: B — Levodopa
Why: When motor symptoms affect quality of life, levodopa is first-line; dopamine agonists/MAO-B inhibitors are for milder impact.
Options:- For milder QoL impact.
- (correct)
- Worsens PD.
- Worsens PD.
- Adjunct.
Seizures & epilepsyCoretap to open ▾
Epilepsy = recurrent unprovoked seizures; specialist-led diagnosis and drugs. Generalised tonic-clonic: valproate (NOT if able to become pregnant → lamotrigine/levetiracetam). Focal: lamotrigine/levetiracetam. Status ≥5 min → benzodiazepine. DVLA: 12 months seizure-free (Group 1).
Classify: Focal vs generalised; absence (ethosuximide); JME.
First-line: GTC: valproate (avoid if childbearing potential); focal: lamotrigine/levetiracetam.
Status epilepticus: ≥5 min → benzodiazepine → phenytoin → phenobarbitone → GA.
Valproate: MHRA: not in those able to become pregnant (PPP); restrictions in under-55s.
A 24-year-old woman with generalised tonic-clonic epilepsy needs a first-line drug and may conceive. Best choice?
- ASodium valproate
- BLamotrigine
- CPhenytoin
- DCarbamazepine
- EEthosuximide
Correct: B — Lamotrigine
Why: Valproate is contraindicated in those who could become pregnant; lamotrigine (or levetiracetam) is first-line for generalised seizures in this group.
Options:- Teratogenic — avoid.
- (correct)
- Not first-line.
- Can worsen generalised seizures.
- Absence only.
Neuropathic painCoretap to open ▾
Burning/shooting/tingling nerve pain, poorly responsive to ordinary analgesia. First-line: amitriptyline, duloxetine, gabapentin or pregabalin (switch if one fails). Trigeminal neuralgia is the exception → carbamazepine.
Recognise: Burning, shooting, allodynia; diabetic, post-herpetic, sciatica, chemo.
First-line: Amitriptyline / duloxetine / gabapentin / pregabalin — switch, don’t stack.
Exception: Trigeminal neuralgia → carbamazepine.
A diabetic has burning, tingling foot pain unresponsive to paracetamol. First-line option?
- ACodeine
- BAmitriptyline
- CIbuprofen
- DTramadol
- EMorphine
Correct: B — Amitriptyline
Why: Neuropathic pain is treated first-line with amitriptyline, duloxetine, gabapentin or pregabalin; opioids and NSAIDs are ineffective.
Options:- Opioid ineffective.
- (correct)
- NSAID ineffective.
- Opioid.
- Opioid.
Multiple sclerosisImportanttap to open ▾
CNS demyelination disseminated in time and space; young adults; optic neuritis, sensory/motor/cerebellar relapses. Relapse = new symptoms >24 h without fever. Acute relapse → methylprednisolone. DMTs specialist-led.
Features: Optic neuritis, Uhthoff’s (heat), Lhermitte’s; relapsing-remitting most common.
Diagnose: Lesions disseminated in time and space; MRI/CSF support.
Manage: Relapse → high-dose methylprednisolone; symptom control; DMTs (specialist).
A 30-year-old woman has painful monocular visual loss with reduced colour vision. What is the likely first presentation of MS?
- ACluster headache
- BOptic neuritis
- CBell’s palsy
- DMigraine aura
- ECataract
Correct: B — Optic neuritis
Why: Optic neuritis (painful monocular loss, colour desaturation, RAPD) is a common first presentation of MS.
Options:- Unrelated.
- (correct)
- Facial, not visual.
- Transient, painless.
- Painless, gradual.
Motor neurone diseaseImportanttap to open ▾
Mixed UMN + LMN signs with PRESERVED sensation and no sphincter/eye involvement. Riluzole modestly extends survival (monitor LFTs); NIV for respiratory support. Poor prognosis (median 2–3 years).
Hallmark: Combined UMN + LMN signs; sensation and eye movements spared.
Types: ALS, progressive bulbar palsy, progressive muscular atrophy.
Manage: Riluzole (LFT monitoring), NIV, MDT; drooling → antimuscarinic.
A 60-year-old has wasting and fasciculation with brisk reflexes and entirely normal sensation. Most likely diagnosis?
- AMultiple sclerosis
- BMotor neurone disease
- CGuillain-Barré
- DPeripheral neuropathy
- EMyasthenia gravis
Correct: B — Motor neurone disease
Why: Mixed upper and lower motor neurone signs with preserved sensation are characteristic of motor neurone disease.
Options:- Has sensory/visual signs.
- (correct)
- Areflexic, acute.
- Sensory loss.
- Fatigable, no wasting early.
Myasthenia gravisImportanttap to open ▾
Fatigable weakness — ptosis/diplopia worse at the end of the day, worse with use. Anti-AChR antibodies; associated with thymoma. Treat pyridostigmine ± immunosuppression. Myasthenic crisis → respiratory support. Beware exacerbating drugs (beta-blockers, aminoglycosides, macrolides).
Features: Fatigable ptosis, diplopia, bulbar and proximal weakness worsening through the day.
Investigate: Anti-acetylcholine-receptor antibodies; CT thorax for thymoma.
Treat: Pyridostigmine; steroids/immunosuppression; avoid exacerbating drugs.
A 40-year-old has drooping eyelids and double vision that worsen through the day and improve with rest. First-line treatment?
- APrednisolone alone
- BPyridostigmine
- CPropranolol
- DGabapentin
- EBaclofen
Correct: B — Pyridostigmine
Why: Fatigable weakness is myasthenia gravis; pyridostigmine (anticholinesterase) is first-line symptomatic treatment.
Options:- Added later.
- (correct)
- Can worsen MG.
- Unrelated.
- For spasticity.
SyncopeImportanttap to open ▾
Transient loss of consciousness from global cerebral hypoperfusion. Vasovagal (prodrome, provoked, quick recovery) vs cardiac (exertional, no warning, injury — red flag). All get a 12-lead ECG; cardiac features → refer.
Vasovagal: Prodrome (nausea, sweating), provoked (standing, pain), rapid recovery — reassure.
Cardiac red flags: Exertional or supine syncope, no prodrome, injury, family history of sudden death → ECG + refer.
First test: 12-lead ECG in everyone with syncope.
A young man faints during exercise with no warning and sustains an injury. What is the priority?
- AReassure — vasovagal
- B12-lead ECG and cardiology referral
- CAdvise more fluids
- DEEG
- ENo action
Correct: B — 12-lead ECG and cardiology referral
Why: Exertional syncope without prodrome is a cardiac red flag (e.g. HOCM, long QT); do an ECG and refer.
Options:- Red flags argue against vasovagal.
- (correct)
- Insufficient.
- Not first for syncope.
- Unsafe.
TremorImportanttap to open ▾
Resting pill-rolling tremor (improves with movement) = Parkinson's. Postural/action tremor worse with movement, improves with alcohol, familial = essential tremor (propranolol first-line). Intention tremor = cerebellar.
Resting: Parkinson’s — pill-rolling, improves on action.
Postural/action: Essential tremor — familial, alcohol-responsive; propranolol first-line.
Intention: Cerebellar disease.
A patient has a bilateral hand tremor that worsens on reaching for a cup and improves after a glass of wine, with a family history. Diagnosis?
- AParkinson's disease
- BEssential tremor
- CCerebellar tremor
- DPhysiological tremor
- EDystonic tremor
Correct: B — Essential tremor
Why: An action tremor that is familial and alcohol-responsive is essential tremor; propranolol is first-line.
Options:- Rest tremor, not action.
- (correct)
- Intention, with other signs.
- Not familial/alcohol-responsive.
- Different.
Gait disordersImportanttap to open ▾
Recognise patterns: parkinsonian (shuffling, festinant, reduced arm swing), cerebellar/ataxic (broad-based), spastic (scissoring, UMN), high-stepping (foot drop, LMN/peripheral), waddling (proximal myopathy).
Parkinsonian: Shuffling, reduced arm swing, festination, freezing.
Ataxic: Broad-based, unsteady — cerebellar or sensory.
High-stepping: Foot drop (common peroneal / L5).
Waddling: Proximal myopathy / pelvic girdle weakness.
A patient walks with a broad-based, unsteady gait and has past-pointing and nystagmus. Which localisation?
- AParkinsonian
- BCerebellar/ataxic
- CSpastic
- DHigh-stepping
- EWaddling
Correct: B — Cerebellar/ataxic
Why: A broad-based unsteady gait with cerebellar signs (nystagmus, past-pointing) is an ataxic (cerebellar) gait.
Options:- Shuffling.
- (correct)
- Scissoring/UMN.
- Foot drop.
- Proximal weakness.
Bulbar vs pseudobulbar palsyImportanttap to open ▾
Bulbar (LMN of lower cranial nerves): flaccid/wasted fasciculating tongue, absent jaw jerk, nasal speech. Pseudobulbar (UMN, bilateral): spastic small tongue, brisk jaw jerk, emotional lability.
Bulbar (LMN): Wasted fasciculating tongue, absent/normal jaw jerk, nasal quiet speech.
Pseudobulbar (UMN): Spastic tongue, brisk jaw jerk, emotional lability (labile affect).
Cause: Both seen in MND; pseudobulbar also in bilateral strokes/MS.
A patient has a spastic tongue, a brisk jaw jerk and emotional lability. Which palsy is this?
- ABulbar (LMN)
- BPseudobulbar (UMN)
- CFacial nerve palsy
- DMyasthenia
- ECerebellar
Correct: B — Pseudobulbar (UMN)
Why: A brisk jaw jerk, spastic tongue and emotional lability indicate a pseudobulbar (upper motor neurone) palsy.
Options:- LMN gives fasciculation/absent jaw jerk.
- (correct)
- Different.
- Fatigable, different.
- Different.
Facial nerve palsy & Bell's palsyImportanttap to open ▾
LMN facial palsy involves the forehead; Bell's palsy is idiopathic LMN palsy — start prednisolone within 72 hours + eye protection. UMN palsy (spares forehead) = stroke. Consider Ramsay Hunt (vesicles) → add aciclovir.
Localise: Forehead involved = LMN (Bell’s); forehead spared = UMN (stroke).
Bell’s: Prednisolone within 72 h; lubricate/tape the eye; most recover.
Ramsay Hunt: Zoster of geniculate ganglion — ear vesicles → aciclovir + steroid.
A 35-year-old has a sudden one-sided facial droop INVOLVING the forehead, with no other signs. First-line treatment?
- AAspirin (treat as stroke)
- BPrednisolone within 72 hours + eye care
- CCarbamazepine
- DAciclovir alone
- ENo treatment
Correct: B — Prednisolone within 72 hours + eye care
Why: Forehead involvement indicates a lower motor neurone (Bell’s) palsy; start prednisolone within 72 hours and protect the eye.
Options:- Forehead sparing would suggest stroke.
- (correct)
- For trigeminal neuralgia.
- Only if Ramsay Hunt.
- Steroids improve outcome.
Nerve problems (mononeuropathies)Rare · recognise
Radial (wrist drop), ulnar (claw hand, C8/T1), median (carpal tunnel), common peroneal (foot drop, fibular neck), axillary (deltoid), Erb’s/Klumpke’s (brachial plexus).
MyopathyRare · recognise
Proximal, symmetrical weakness (difficulty rising/combing hair), often painless; raised CK. Causes: inflammatory (poly/dermatomyositis), drugs (statins, steroids), endocrine (thyroid, Cushing’s), inherited dystrophies.
Weakness & fatigue: approachRare · recognise
Localise: brain/cord (UMN), root/nerve (LMN, dermatomal), NMJ (fatigable — MG), muscle (proximal — myopathy). ‘Fatigue’ alone is usually non-neurological — screen anaemia, thyroid, depression, sleep.