KFP – Neurological presentations

Andrea Mitchell, aged 38, presents with sudden-onset right-sided facial weakness that began this morning. She reports difficulty closing her right eye and drooling from the right side of her mouth. She denies any limb weakness, slurred speech, or sensory disturbance. She has no headache, neck pain, or recent trauma. She recalls feeling mildly unwell with a sore throat and ear pain on the right side two days ago.

Medications: Occasional paracetamol

Allergies: Nil known

Past history: Unremarkable

Family history: No relevant conditions

Social history: Non-smoker, social alcohol use, works as a primary school teacher

Examination findings: Right-sided lower motor neuron facial nerve palsy. No forehead sparing. No limb weakness or cerebellar signs. Cranial nerves otherwise intact. No vesicles or rash seen in the ear canal or on the face. Otoscopy shows mild erythema of the right tympanic membrane. No mastoid tenderness. Vitals normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Samuel Howarth, a 69-year-old retired accountant, presents to your clinic with his wife who is concerned about his memory. Over the past 12 months, Samuel has become increasingly forgetful, often misplacing items, repeating questions, and occasionally getting lost while driving in familiar areas. His sleep is normal, mood is neutral, and he remains independent in basic activities of daily living, though his wife has begun managing finances and medication reminders.

Medications: Atorvastatin, irbesartan

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia

Family history: Father had Alzheimer’s disease

Social history: Lives with wife, non-smoker, drinks 2–3 standard drinks/week, walks daily

Examination findings: Oriented to person and place, unsure of date. MMSE score 24/30. No focal neurological signs. Cranial nerves, gait and coordination normal. Mood appears euthymic. No hallucinations or tremor.

What are the most appropriate next steps in management? Select four (4) from the following list:

Kylie Donoghue, a 24-year-old barista, presents with recurrent episodes of transient loss of awareness. Her partner reports that during these episodes, Kylie stares blankly, smacks her lips, and is unresponsive for 20–30 seconds. Afterwards, she is briefly confused and tired. The episodes have become more frequent, occurring twice in the past week. She has no known history of epilepsy and has never experienced generalised tonic-clonic seizures.

Medications: Oral contraceptive pill

Allergies: Nil known

Past history: Migraines (childhood, resolved), appendectomy at age 12

Social history: Lives with partner, does not drive, no alcohol or drug use

Examination findings: Vital signs normal. Cardiovascular, respiratory, and neurological examination unremarkable. GCS 15, no focal deficits.

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Peter Callaghan, a 58-year-old man, presents with a six-month history of gradually worsening unsteadiness and numbness in his feet. He describes difficulty walking, especially in the dark, and says his legs feel ‘heavy’. He has also noticed erectile dysfunction and occasional urinary urgency. He denies pain, recent infection, or exposure to toxins.

Medications: Omeprazole (over-the-counter use for reflux)

Allergies: Nil known

Past history: Hypertension, chronic gastritis

Family history: Father had type 2 diabetes

Social history: Retired schoolteacher, moderate alcohol intake (2–3 drinks most nights), ex-smoker

Examination findings: Normal cranial nerves. Romberg’s sign positive. Decreased vibration sense to the knees, reduced proprioception in toes. Reflexes brisk in lower limbs with bilateral upgoing plantar responses. Mild broad-based gait. No cerebellar signs or limb ataxia. Upper limb and cognitive exams normal.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Ahmed El-Amin, a 32-year-old electrician, presents to your clinic with a three-day history of progressively worsening headache, fever, and photophobia. He reports associated neck stiffness and nausea. He denies recent travel, trauma or sick contacts. No rash is noted. He has no known immunocompromising conditions.

Medications: Nil

Allergies: Nil known

Past history: Childhood asthma

Social history: Lives with partner, non-smoker, no alcohol or drug use

Examination findings: Temperature 38.7°C. GCS 15. HR 102 bpm, BP 120/80 mmHg. Positive Kernig’s sign and photophobia. No focal neurological deficits. No papilloedema. Cardiovascular, respiratory and abdominal exams are unremarkable.

What are the most appropriate next steps in management? Select four (4) from the following list:

Tracey Barlow, a 45-year-old administrative assistant, presents to your rural practice with a five-day history of new-onset severe, right-sided facial pain. She describes the pain as sharp and electric, triggered by chewing, brushing her teeth, and wind on her face. It lasts for a few seconds but is intense and disabling. She has had no visual changes, rashes, fever, or limb weakness. She is distressed and has had difficulty eating due to fear of triggering pain.

Medications: Nil

Allergies: Nil known

Past history: Migraine (last episode 5 years ago)

Social history: Lives with partner, does not smoke, minimal alcohol

Examination findings: Normal cranial nerve examination including corneal reflexes and facial sensation. No rash or vesicles. No limb neurological signs. Vitals normal. No signs of jaw claudication or temporal artery tenderness.

What are the most appropriate next steps in management? Select three (3) from the following list:

Steven McAllister, a 61-year-old truck driver, presents with a two-month history of progressively worsening difficulty using his hands and intermittent fasciculations in his right arm. He reports recent trouble with fine motor tasks like buttoning shirts and notices frequent muscle cramps. He has also experienced occasional slurred speech, especially when tired. There is no sensory loss, diplopia, bowel/bladder dysfunction, or visual symptoms.

Medications: Ramipril

Allergies: Nil known

Past history: Hypertension, hypercholesterolaemia

Family history: Father died of myocardial infarction at age 64; no neurological disorders

Social history: Non-smoker, drinks 2–3 beers/night. Long-haul truck driver for 30 years

Examination findings: Mild dysarthria, fasciculations in the right biceps and forearm. Weakness of finger extension and grip bilaterally. Brisk upper and lower limb reflexes. No sensory deficit. Normal cerebellar signs. No tremor. Gait is normal.

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Grace Ncube, a 72-year-old retired teacher, presents with a three-month history of progressively worsening imbalance, urinary urgency, and mild memory impairment. Her daughter reports that Grace has had several near-falls and often walks with a wide-based, shuffling gait. Grace denies focal weakness or sensory changes. She lives independently but has become more forgetful and less organised with medications and appointments.

Medications: Perindopril, simvastatin

Allergies: Nil known

Past history: Hypertension, osteoarthritis

Family history: Non-contributory

Social history: Lives alone, no smoking or alcohol

Examination findings: Gait is broad-based and magnetic. Cognition mildly impaired (GPCOG 5/9). No focal motor or sensory deficit. Reflexes normal. Continence preserved but reports urinary urgency. Cranial nerves intact. No tremor or cerebellar signs.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Daniel Xu, a 16-year-old high school student, presents to your clinic following an episode of sudden collapse during a school athletics event. Witnesses report he was running when he suddenly stiffened, fell to the ground, and began jerking all four limbs for around one minute. He was unresponsive throughout and took several minutes to regain full consciousness. This is his first seizure. He denies recent illness, sleep deprivation or substance use.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives with parents, Year 11 student, no alcohol or recreational drugs. Plays competitive sport

Examination findings: Alert and oriented. No focal neurological deficits. Cardiovascular and respiratory exams unremarkable. Vitals normal. Post-ictal bite on side of tongue noted. No head injury observed.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Linda Tsiang, a 48-year-old primary school teacher, presents with a four-month history of persistent dizziness and imbalance. She describes a sensation of the room ‘spinning’ that is triggered when rolling over in bed or looking up. Episodes last less than a minute. She denies hearing loss, tinnitus, nausea or headache. No recent infections or trauma.

Medications: Nil regular

Allergies: Nil known

Past history: Migraine in her 20s (resolved), hypothyroidism

Social history: Lives with her partner, no smoking, minimal alcohol

Examination findings: Cardiovascular, respiratory and neurological exams are normal. Dix-Hallpike manoeuvre on the right side reproduces vertigo with nystagmus. Left side is negative. Gait and coordination are intact.

What are the most appropriate next steps in management? Select three (3) from the following list:

Malcolm Rivers, a 73-year-old retired plumber, presents with a one-month history of visual hallucinations and fluctuating confusion. His wife reports episodes of vivid, detailed hallucinations involving people and animals that Malcolm recognises are not real. He is intermittently lucid but has episodes of significant confusion, particularly in the evening. She has also noticed his walking has slowed, and he appears stiff and occasionally shuffles his feet. There is no history of stroke or trauma.

Medications: Aspirin, simvastatin

Allergies: Nil known

Past history: Ischaemic heart disease

Family history: Mother had dementia in her 80s

Social history: Lives with wife, no smoking or alcohol

Examination findings: Mild cogwheel rigidity in upper limbs bilaterally. Gait is slow with reduced arm swing. GPCOG 4/9. Alert, but attention fluctuates during consultation. Cranial nerves normal. No tremor noted.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Angela Deering, a 34-year-old office worker, presents with a two-week history of right eye blurred vision and pain on eye movement. She describes it as a gradual onset, associated with mild colour desaturation. She has no headache, fever, or photophobia. She reports a similar episode of left leg weakness and numbness lasting a few days about a year ago, which resolved spontaneously and was never investigated.

Medications: Oral contraceptive pill

Allergies: Nil known

Past history: Migraine with aura (in teens)

Social history: Lives with partner, non-smoker, occasional alcohol

Examination findings: Right eye shows reduced visual acuity, afferent pupillary defect, and impaired colour vision. Fundoscopy normal. Left leg strength and sensation normal. No other cranial nerve abnormalities. Reflexes brisk but symmetric. No cerebellar signs.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Bernadette Kelly, a 67-year-old retired librarian, presents with a sudden onset of right-sided weakness and slurred speech that began approximately 90 minutes ago while gardening. Her symptoms partially improved on arrival to your rural clinic. She denies headache, seizures, or prior similar events. Her past history includes type 2 diabetes, hypertension, and atrial fibrillation.

Medications: Metformin, perindopril, warfarin

Allergies: Nil known

Past history: As above

Social history: Lives with husband, independent in ADLs

Examination findings: BP 158/84 mmHg, HR 82 bpm irregular. Speech mildly dysarthric. Right arm and leg weakness (4/5). Sensation intact. NIHSS score: 3. No facial droop. No neck stiffness. ECG confirms atrial fibrillation.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Renee Dawson, a 28-year-old graphic designer, presents with episodes of sudden, intense, one-sided headaches over the past two months. The pain is located around her left eye, lasts about 30 to 45 minutes, and occurs daily for 1–2 weeks before resolving completely for weeks at a time. She describes associated tearing, nasal congestion, and eyelid swelling on the affected side. The pain is so severe she cannot sit still during attacks. There is no aura, photophobia, or nausea.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Migraine in her mother

Social history: Non-smoker, drinks socially, no recreational drugs

Examination findings: Vitals normal. Neurological exam normal between attacks. No ptosis or Horner’s syndrome noted currently. Eye exam normal. Nasal mucosa mildly congested on left. GPCOG normal.

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Thomas Varga, a 55-year-old builder, presents with a three-month history of gradually worsening bilateral hand numbness and nocturnal tingling. Symptoms are worse at night and improve with shaking his hands. He reports occasional clumsiness with tools but no weakness. He has no neck pain, visual changes, or lower limb symptoms. He uses power tools daily.

Medications: Paracetamol PRN

Allergies: Nil known

Past history: Type 2 diabetes (well controlled), hypertension

Social history: Lives with wife, smokes 5 cigarettes/day, drinks 1–2 beers/night

Examination findings: Tinel’s sign and Phalen’s manoeuvre positive bilaterally. Thenar wasting not observed. Sensation reduced over the thumb, index, and middle fingers bilaterally. Motor strength normal. Reflexes intact and symmetrical. No signs of cervical myelopathy.

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Dominic Shields, a 62-year-old semi-retired accountant, presents with a six-week history of progressively worsening lower back pain radiating down his left leg to the foot. The pain is described as sharp and burning, worse with sitting, and associated with tingling in the sole of the left foot. He has been taking over-the-counter ibuprofen with limited relief. No bowel or bladder dysfunction. No recent trauma.

Medications: Irbesartan, simvastatin

Allergies: Nil known

Past history: Hypertension, hypercholesterolaemia

Social history: Lives with wife, ex-smoker, no alcohol use

Examination findings: Antalgic gait. Decreased sensation in the left S1 dermatome. Weakness of left plantarflexion (4/5). Ankle reflex diminished on the left. Straight leg raise positive at 40 degrees. No saddle anaesthesia or loss of anal tone.

What are the most appropriate next steps in management? Select three (3) from the following list:

Melanie Russo, a 42-year-old paramedic, presents with a one-month history of persistent fatigue, muscle cramps, and generalised weakness, particularly affecting her proximal limbs. She reports difficulty climbing stairs and lifting objects overhead. There is no pain, numbness, or visual disturbance. She denies weight loss, fevers, or recent illness. No family history of neuromuscular disease.

Medications: Atorvastatin, vitamin D

Allergies: Nil known

Past history: Hypercholesterolaemia

Social history: Lives with partner, two children. No alcohol or drug use. Ex-smoker.

Examination findings: Proximal muscle weakness in both upper and lower limbs (4/5). Reflexes normal. No fasciculations or sensory deficits. Gait slightly waddling. Cranial nerves intact. No rash or joint signs. Cognition intact.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Hannah Greaves, a 25-year-old university student, presents following a witnessed syncopal episode during a tutorial. She felt light-headed and warm before briefly losing consciousness while standing. She was unresponsive for about 10 seconds, with no limb jerking or incontinence. She recovered spontaneously and was alert within a minute. She reports feeling tired and mildly nauseated after the event. No previous episodes, no palpitations or chest pain. No known cardiac disease.

Medications: Combined oral contraceptive pill

Allergies: Nil known

Past history: Nil significant

Social history: Lives in student housing, non-smoker, occasional alcohol

Examination findings: HR 72 bpm, BP 112/72 mmHg supine, 98/68 mmHg standing. Cardiorespiratory and neurological exams normal. ECG normal sinus rhythm. No murmur, JVP not elevated. No focal neurological deficit. Capillary glucose normal.

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Geoff McKenzie, a 75-year-old retired farmer, presents with his wife who is concerned about his increasing drowsiness and unsteadiness over the past 10 days. She also reports a recent change in his personality and memory. Three weeks ago, he fell while gardening and hit the left side of his head but did not lose consciousness. No vomiting, seizure, or focal weakness. He has a history of hypertension and atrial fibrillation (not anticoagulated).

Medications: Perindopril, simvastatin

Allergies: Nil known

Past history: Atrial fibrillation (no warfarin due to prior GI bleeding), hypertension

Social history: Lives with wife on rural property. Non-smoker. No alcohol.

Examination findings: GCS 14. Mild right-sided pronator drift. Slightly broad-based gait. Mild expressive dysphasia. Cranial nerves intact. No papilloedema. BP 134/80, HR 92 irregularly irregular. Blood glucose normal.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Nadia Patel, a 30-year-old medical registrar, presents with recurrent episodes of left arm and facial numbness followed by difficulty speaking. Each episode lasts about 20 minutes and resolves completely. She has experienced three such episodes over the last two weeks. She denies headache, visual changes, or limb weakness. No prior history of migraine or seizures. No smoking or substance use. She is on the combined oral contraceptive pill.

Medications: Ethinylestradiol/levonorgestrel

Allergies: Nil known

Past history: Nil significant

Social history: Lives with partner, no alcohol, active lifestyle

Examination findings: Neurological exam is normal. Vitals normal. No bruits. No signs of endocarditis. ECG shows normal sinus rhythm. GPCOG 9/9.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Kevin Liang, a 38-year-old software engineer, presents with an eight-month history of intermittent electric shock-like pain radiating down the back of his neck into both arms, triggered by neck flexion. He also reports hand clumsiness and unsteady gait, which has worsened over the past few months. No history of trauma. No visual symptoms, bowel or bladder dysfunction. No systemic features.

Medications: Nil regular

Allergies: Nil known

Past history: Nil significant

Social history: Lives with partner, works full-time, recreational cyclist

Examination findings: Hoffmann’s sign positive bilaterally. Mild weakness in hand grip bilaterally. Hyperreflexia in all limbs. Gait is broad-based with difficulty tandem walking. Vibration sense reduced in feet. No cranial nerve abnormalities. No fasciculations or muscle atrophy observed.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Elise Fournier, a 58-year-old woman, presents with gradual onset of right-sided hearing loss, imbalance, and occasional tinnitus over the past six months. She also reports a sensation of fullness in the right ear. There are no episodes of vertigo, headaches, or facial weakness. She works as a piano teacher and has become concerned about her hearing affecting her work. No noise exposure or ototoxic medications.

Medications: Perindopril

Allergies: Nil known

Past history: Hypertension

Social history: Lives alone, active, non-smoker, occasional wine

Examination findings: Rinne test is positive bilaterally. Weber test lateralises to the left. Cranial nerve exam otherwise normal. No facial asymmetry. Tandem gait mildly impaired. Romberg’s test negative. Otoscopy normal.

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

David Lennox, a 63-year-old retired teacher, presents with a 3-month history of tremor in his right hand. His wife has noticed that his handwriting has become smaller and more cramped. He also reports a feeling of stiffness and slowness when walking, especially when getting out of bed in the morning. He denies any falls, dizziness, or cognitive changes.

Medications: Nil

Allergies: Nil known

Past history: Hypertension (well controlled)

Social history: Lives with wife, active, plays bowls. No alcohol or smoking.

Examination findings: Resting tremor in the right hand, decreased right arm swing while walking, mild bradykinesia on finger tapping on the right. Rigidity present in the right upper limb. No postural instability. MMSE 29/30. Cranial nerves intact. No cerebellar or sensory deficits.

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Sarah Boyd, a 19-year-old university student, presents with a 3-month history of frequent headaches. She describes a pulsatile, bilateral headache occurring on most days of the week, often worse in the mornings. She also reports blurred vision at times and transient visual obscurations, especially when standing up quickly. There is no vomiting or neck stiffness. She has gained 10 kg over the past 6 months. No previous neurological conditions.

Medications: Combined oral contraceptive pill

Allergies: Nil known

Past history: Polycystic ovarian syndrome (PCOS)

Social history: Lives in college dorms, minimal alcohol, no smoking

Examination findings: BMI 34. BP 118/78. Visual acuity normal. Fundoscopy reveals bilateral papilloedema. No cranial nerve palsies. Neurological examination otherwise normal.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Michael Tran, a 50-year-old warehouse worker, presents with a two-month history of progressive numbness and tingling in both feet, now extending to his hands. He describes a ‘stocking-glove’ pattern of sensory loss and mild burning discomfort in his toes. He denies weakness, back pain, or recent infections. No alcohol intake. He has lost 6 kg unintentionally over the past three months.

Medications: Metformin, gliclazide

Allergies: Nil known

Past history: Type 2 diabetes (diagnosed 5 years ago)

Social history: Lives alone, independent, no alcohol or smoking

Examination findings: Vitals normal. Symmetrical loss of vibration and pinprick sensation in both feet and distal hands. Reflexes reduced at the ankles, preserved at knees. Gait normal. No muscle wasting or weakness. Cranial nerves intact.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Felicity O’Rourke, a 47-year-old schoolteacher, presents with frequent episodes of sudden, brief loss of awareness. Her husband has witnessed her staring blankly for about 10–15 seconds, sometimes with lip-smacking or finger rubbing. These episodes occur multiple times per day and have gradually increased in frequency over the past few months. She is unaware of the episodes. No prior seizures, no alcohol or drug use. No recent illness or trauma.

Medications: Nil

Allergies: Nil known

Past history: Migraine (inactive)

Social history: Lives with husband, non-smoker, social drinker

Examination findings: Neurological examination normal. GPCOG 9/9. No motor or sensory deficits. Cardiovascular and respiratory exams unremarkable. Vitals stable. No post-ictal confusion or focal findings.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

William Doukas, a 69-year-old retired mechanic, presents with a 3-week history of worsening headache, nausea, and confusion. His wife reports that he has become increasingly irritable, forgetful, and occasionally drowsy during the day. There is no history of trauma, seizures, or visual changes. He has type 2 diabetes and was recently treated for a sinus infection with oral antibiotics.

Medications: Metformin, rosuvastatin

Allergies: Nil known

Past history: Type 2 diabetes, hypertension, chronic sinusitis

Social history: Lives with wife, ex-smoker, no alcohol

Examination findings: GCS 14. Mild right-sided weakness and expressive dysphasia. Temperature 37.8°C. Fundoscopy: papilloedema. Cranial nerves otherwise intact. No neck stiffness. Reflexes brisk on the right. No rash.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Amira Singh, a 35-year-old primary school teacher, presents with a one-week history of progressive bilateral lower limb weakness and numbness. She reports difficulty walking and rising from a chair. She also noticed tingling in her feet that began a few days before the weakness. There is no bladder or bowel dysfunction. She had a self-limiting diarrhoeal illness two weeks ago. No recent trauma or travel.

Medications: Nil regular

Allergies: Nil known

Past history: Nil significant

Social history: Lives with partner, works full-time, non-smoker, no alcohol

Examination findings: Flaccid weakness in both legs (3/5), absent ankle and knee reflexes bilaterally. Sensation reduced in a stocking distribution. Upper limbs mildly weak (4+/5). Cranial nerves intact. Vitals: HR 88, BP 118/74, RR 16, SpO2 98% RA. No facial droop or dysarthria.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Rachel Goodwin, a 41-year-old social worker, presents with episodes of sudden, severe, stabbing pain affecting the right side of her face, particularly around the cheek and jaw. The pain lasts for a few seconds but recurs in clusters multiple times per day. It is triggered by brushing her teeth, chewing, and even wind on her face. She has no facial weakness or numbness, and no visual symptoms or rashes. This has been occurring intermittently for the past month and is increasing in frequency.

Medications: Nil

Allergies: Nil known

Past history: Migraine (in remission)

Social history: Lives with partner, no alcohol or smoking

Examination findings: Cranial nerves intact. No sensory loss in trigeminal distribution. No facial asymmetry. Jaw strength and corneal reflex normal. No vesicular lesions or rash.

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Patrick Mooney, a 59-year-old truck driver, presents with a six-month history of gradually worsening difficulty swallowing solids and, more recently, liquids. He also reports a hoarse voice and frequent coughing during meals. There is no weight loss or neck pain. His wife has noticed he occasionally drools and seems to have facial twitching. He denies limb weakness or sensory changes.

Medications: Omeprazole

Allergies: Nil known

Past history: Gastro-oesophageal reflux disease

Social history: Smokes 10 cigarettes/day, drinks 2–3 beers/night, lives with wife

Examination findings: Speech is slurred with a nasal quality. Tongue shows fasciculations and mild atrophy. Gag reflex absent. Cranial nerves otherwise intact. No limb weakness or sensory loss. Reflexes brisk in all limbs. Plantar responses upgoing bilaterally. Gait not assessed due to fatigue.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Yousef Al-Khatib, a 45-year-old IT consultant, presents with episodes of right-sided facial weakness that resolve spontaneously within a few hours. He describes this as a facial droop with difficulty closing his right eye and smiling symmetrically. It has occurred three times over the past month. He denies limb weakness, visual disturbance, or sensory loss. There is no headache, ear pain, or rash. No significant past medical history. No recent illness or trauma.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Non-smoker, minimal alcohol, lives with partner

Examination findings: Currently normal. No facial asymmetry. Cranial nerves, coordination, and gait all intact. Reflexes normal. Cardiovascular and ENT exams unremarkable.

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Angela Petrou, a 60-year-old woman, presents with a sudden onset of unsteady gait and dizziness that began this morning. She reports nausea, vomiting, and a sensation of the room spinning. The symptoms began while she was gardening and worsened when turning her head. She denies hearing loss, headache, weakness, or visual changes. No fever or neck stiffness. No previous episodes. Her past history includes hypertension and dyslipidaemia.

Medications: Amlodipine, atorvastatin

Allergies: Nil known

Past history: As above

Social history: Lives with husband, non-smoker, occasional wine

Examination findings: BP 140/86, HR 84. Horizontal nystagmus present, worsens when looking to the left. Positive head impulse test to the left. Normal limb strength and coordination. Gait broad-based but steady with support. No dysarthria or diplopia. Finger-nose testing normal.

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Connor Eldridge, a 27-year-old law student, presents with sudden onset of weakness and numbness in his right leg that began on waking this morning. He reports no trauma or exertion. He also describes intermittent visual blurring in his right eye over the past week that resolved spontaneously. He denies headache, dizziness, or recent illness. No bowel or bladder symptoms. No family history of neurological disease.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives alone, non-smoker, occasional alcohol

Examination findings: Right leg strength 3/5 proximally and distally. Decreased pinprick and vibration sense in right leg. Reflexes brisk on right side with upgoing plantar. Cranial nerves intact. Gait mildly unsteady. No dysarthria or coordination deficits.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Sophie Nguyen, a 32-year-old graphic designer, presents with persistent right-sided throbbing headaches for the past four months. The headaches occur about twice per week, lasting several hours, and are accompanied by nausea, photophobia, and sometimes visual disturbances described as shimmering zig-zag lines lasting 20 minutes before the pain starts. She has no focal neurological deficits between episodes. No recent trauma, fever, or red flags. Menstrual cycle appears to trigger some attacks.

Medications: Combined oral contraceptive pill

Allergies: Nil known

Past history: Nil significant

Social history: Lives with partner, non-smoker, drinks socially

Examination findings: Vitals normal. Neurological examination completely normal. Fundoscopy unremarkable. Gait normal.

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Trevor Atkinson, a 72-year-old retired engineer, presents with a 2-month history of progressive forgetfulness, word-finding difficulty, and recent trouble managing his finances. His wife notes that he repeats questions and occasionally becomes disoriented in familiar places. He has no delusions, hallucinations, or recent head trauma. No alcohol or drug use. No history of stroke. He was previously independent in daily activities.

Medications: Perindopril, simvastatin

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia

Social history: Lives with wife, non-smoker, no alcohol

Examination findings: BP 132/76. MMSE 23/30 with deficits in recall and orientation. GPCOG score 6/9 (informant section confirms decline). Neurological examination otherwise normal. No focal deficits, gait normal.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Samuel Carter, a 48-year-old forklift operator, presents with a 6-week history of persistent headaches, worse in the early morning and occasionally waking him from sleep. He describes them as dull and bilateral, sometimes associated with nausea but no vomiting. Over the past week, he has developed blurry vision and difficulty reading. No fever, seizures, trauma, or recent illness. No history of migraines or family history of neurological disease.

Medications: Paracetamol as needed

Allergies: Nil known

Past history: Hypertension, well controlled

Social history: Lives with wife, smokes 5 cigarettes/day, drinks socially

Examination findings: BP 144/86, HR 78. GCS 15. Papilloedema noted bilaterally on fundoscopy. No cranial nerve palsies. No focal neurological deficits. Coordination and gait normal.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Melissa Harrington, a 25-year-old university student, presents with intermittent episodes of loss of awareness lasting around 30 seconds. During these episodes, she appears dazed, smacks her lips, and fumbles with her hands. Afterward, she is confused for a few minutes. These events have been occurring for several months, but have recently increased in frequency. She denies tonic-clonic movements, incontinence, or tongue biting. No significant medical history.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives in shared housing, no alcohol or drug use, non-smoker

Examination findings: Neurological examination normal. Vitals stable. ECG normal sinus rhythm. GPCOG normal.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Daniela Rossi, a 65-year-old retired pharmacist, presents with acute onset of left-sided facial droop noticed on waking this morning. She reports difficulty closing her left eye, dribbling from the left corner of her mouth, and loss of taste on the front of her tongue. She denies limb weakness, headache, or sensory loss. No speech disturbance, double vision, or vertigo. No prior episodes. No ear pain or rash.

Medications: Perindopril, atorvastatin

Allergies: Nil known

Past history: Hypertension, hypercholesterolaemia

Social history: Lives with husband, non-smoker, occasional wine

Examination findings: Left-sided lower motor neuron facial palsy involving forehead and lower face. No limb weakness. No rash. Cranial nerves otherwise normal. Normal gait and reflexes. BP 134/78.

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

James Te Whare, a 54-year-old Aboriginal man, presents with a 3-month history of gradually progressive bilateral lower limb weakness, difficulty climbing stairs, and frequent falls. He reports numbness and tingling in both feet and a burning sensation in his calves. He also reports erectile dysfunction and occasional episodes of dizziness on standing. He has a 20-year history of poorly controlled type 2 diabetes.

Medications: Metformin, gliclazide, ramipril, atorvastatin

Allergies: Nil known

Past history: Type 2 diabetes, hypertension, dyslipidaemia

Social history: Lives with extended family in a rural community. Smoker (10/day), occasional alcohol use

Examination findings: Decreased vibration and pinprick sensation in stocking distribution. Ankle reflexes absent. Gait unsteady. BP 132/76 supine, 102/64 standing. Cranial nerves intact. No upper motor neuron signs.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Natalie Cummings, a 34-year-old lawyer, presents with a sudden severe headache described as ‘the worst of her life’ that began 30 minutes ago while she was at work. The pain was maximal at onset and is diffuse. She has associated nausea, photophobia, and neck stiffness. No history of migraine or trauma. No focal neurological symptoms reported.

Medications: Combined oral contraceptive pill

Allergies: Nil known

Past history: Migraine ruled out previously, otherwise well

Social history: Non-smoker, drinks socially, no recreational drugs

Examination findings: BP 160/92, HR 88, RR 18. GCS 15. Mild neck stiffness noted. No rash. Cranial nerves and limb strength normal. Fundoscopy not possible due to photophobia.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Henry Botros, a 78-year-old man with a history of atrial fibrillation and hypertension, presents with sudden onset of right-sided weakness and slurred speech that began 45 minutes ago. His wife reports he was well earlier this morning. He has no headache or seizure activity. He is not on anticoagulation due to previous GI bleeding. His symptoms have not improved since onset.

Medications: Perindopril, simvastatin

Allergies: Nil known

Past history: Atrial fibrillation, hypertension, previous GI bleed

Social history: Lives with wife, ex-smoker, no alcohol

Examination findings: BP 142/88, HR 96 irregularly irregular. Right-sided facial droop, right arm and leg weakness (2/5 power), slurred speech. No neck stiffness. Pupils equal and reactive. No rash.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Emily Zhao, a 30-year-old registered nurse, presents with a 6-month history of intermittent episodes of dizziness and hearing loss in her left ear. She reports a sensation of fullness in the ear and low-pitched tinnitus. These episodes last for several hours and are often associated with nausea and imbalance. There is no recent illness or trauma. Between episodes, she feels well.

Medications: Nil regular

Allergies: Nil known

Past history: Nil significant

Social history: Non-smoker, occasional alcohol

Examination findings: Normal ear canal and tympanic membrane. Weber test lateralises to the right ear. Rinne test is positive bilaterally. Romberg’s test mildly positive. No nystagmus at rest. Neurological exam otherwise normal.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Ravi Kapoor, a 62-year-old accountant, presents with a 4-week history of progressive difficulty walking and bilateral leg weakness. He also reports urinary urgency and some difficulty initiating urination. He denies trauma, back pain, or recent infections. No fever or night sweats. No sensory changes in the arms. His gait has become increasingly unsteady, and he now uses a cane for support.

Medications: Metformin, amlodipine

Allergies: Nil known

Past history: Type 2 diabetes, hypertension

Social history: Lives with wife, non-smoker, no alcohol

Examination findings: Lower limb weakness (4/5) bilaterally, increased tone, brisk reflexes, and upgoing plantar responses. Sensory level at T10. Upper limbs normal. Cranial nerves intact.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Kylie O’Donnell, a 29-year-old personal trainer, presents with a 2-week history of worsening double vision and drooping eyelids, especially in the evenings. She also reports difficulty chewing and speaking by the end of the day. Symptoms improve with rest. No headache, limb weakness, or sensory changes. She has not had any recent infections, vaccinations, or trauma. No family history of neurological disease.

Medications: Oral contraceptive pill

Allergies: Nil known

Past history: Nil significant

Social history: Non-smoker, occasional alcohol

Examination findings: Bilateral ptosis, worsens with sustained upward gaze. Mild dysarthria. Diplopia on lateral gaze. No limb weakness or ataxia. Reflexes normal. Pupils equal and reactive. No sensory deficit.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Steven Mills, a 64-year-old retired carpenter, presents with a three-month history of involuntary jerking movements, unsteady gait, and recent memory decline. His wife reports that he is increasingly forgetful, has difficulty concentrating, and has started having visual hallucinations. His movements are unpredictable, and he has had several near falls. No family history of neurological conditions. No known infections. No significant trauma history.

Medications: Rosuvastatin

Allergies: Nil known

Past history: Hyperlipidaemia

Social history: Lives with wife, no alcohol or drug use, non-smoker

Examination findings: GCS 15. Myoclonus present in upper limbs. Broad-based, unsteady gait. MMSE 22/30. Brisk reflexes in all limbs. No focal weakness. Plantar responses upgoing bilaterally.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Lucy Henderson, a 22-year-old university student, presents with a 24-hour history of right-sided facial weakness, ear pain, and a painful red rash around her right ear. She also reports decreased hearing on the right and a metallic taste in her mouth. The symptoms began suddenly and have worsened. She is finding it difficult to close her right eye and has been drooling from the right side of her mouth.

Medications: Nil

Allergies: Nil known

Past history: Atopic dermatitis

Social history: Lives in student housing, non-smoker, drinks occasionally

Examination findings: Right-sided lower motor neuron facial palsy involving forehead and lower face. Vesicular rash in the external auditory canal and on the pinna. Decreased sensation in the right external ear. No limb weakness or other cranial nerve involvement. Tympanic membrane normal. Gait and coordination normal.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Thomas Leung, a 56-year-old financial advisor, presents with a 6-month history of gradually worsening tremor in both hands. He reports that the tremor is most noticeable when using utensils or writing and tends to improve with alcohol. There is no stiffness, bradykinesia, or postural instability. His father had a similar tremor in later life. He denies any recent medication changes or exposure to toxins.

Medications: Nil

Allergies: Nil known

Past history: Mild hypertension (diet controlled)

Social history: Lives with wife, drinks socially, no smoking

Examination findings: Postural and action tremor noted in both hands. No resting tremor. No rigidity, bradykinesia, or gait abnormality. Speech and cognition normal. Cranial nerves and reflexes intact.

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Fatima El-Khoury, a 40-year-old primary school teacher, presents with episodes of intense, stabbing pain on the left side of her face lasting a few seconds each time. The pain is triggered by brushing her teeth, chewing, or even cold air. It occurs in clusters multiple times a day. She denies any facial numbness, rash, or weakness. No headache, visual changes, or hearing issues. These symptoms started three weeks ago and are worsening.

Medications: Nil regular

Allergies: Nil known

Past history: Migraine (in remission)

Social history: Lives with partner, no smoking or alcohol use

Examination findings: Neurological exam normal. Cranial nerves intact. No facial sensory loss or weakness. Normal jaw strength and corneal reflex. No rash or vesicles noted. Vitals stable.

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Jordan Patel, a 67-year-old man, presents with a 2-month history of visual hallucinations, fluctuating cognition, and increasing falls. His wife reports that he seems confused at times but can be quite lucid on other days. He has also developed a coarse resting tremor in both hands and shows stiffness when walking. There is no history of stroke or head trauma. No psychiatric history.

Medications: Rosuvastatin, perindopril

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia

Social history: Lives with wife, ex-smoker, no alcohol

Examination findings: Fluctuating attention and alertness observed during consult. Resting tremor in upper limbs. Increased tone in upper and lower limbs. Slow, shuffling gait. MMSE 24/30 with impaired visuospatial function.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Alana Griffiths, a 46-year-old mining technician, presents with a 3-month history of persistent headaches, fatigue, poor concentration, and memory issues. She describes the headaches as dull, daily, and worse at work. She also reports dizziness, light sensitivity, and difficulty finding words. She sustained a head injury three months ago when a heavy object struck her helmet. She did not lose consciousness but felt ‘dazed’ for several hours afterward.

Medications: Paracetamol as needed

Allergies: Nil known

Past history: Nil significant

Social history: Lives in remote mining camp 2 weeks on/1 week off. Non-smoker. Moderate alcohol on time off.

Examination findings: Alert and oriented. No focal neurological deficits. Gait normal. Fundoscopy normal. Cranial nerves intact. MMSE 28/30 (minor word recall difficulty). Mood slightly flat. Romberg negative.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list: