KMU Past Paper Practice

Question: A 63-year-old woman presents with intermittent shaking of both hands for four years. The shaking becomes prominent when holding a cup or writing and disappears almost completely when her hands are resting on her lap. Examination reveals normal facial expression, normal muscle tone and preserved speed of repetitive movements. Which clinical finding most strongly argues against Parkinson’s disease as the primary diagnosis?

Options:

Correct Answer: Absence of demonstrable bradykinesia

Explanation: Bradykinesia is essential for the clinical diagnosis of parkinsonism. Predominantly action-related tremor without bradykinesia or rigidity favors essential tremor.

Question: A 58-year-old man develops progressive slowness and stiffness several months after starting an antipsychotic medication. Examination reveals bilateral rigidity, reduced arm swing and bradykinesia, but no prominent resting tremor. The medication acts mainly by blocking dopamine D2 receptors. Which diagnostic interpretation is most appropriate?

Options:

Correct Answer: Drug-induced parkinsonism

Explanation: Dopamine D2 receptor blockade in nigrostriatal pathways can produce bradykinesia and rigidity. The temporal relationship with antipsychotic exposure strongly supports drug-induced parkinsonism.

Question: A 70-year-old man with a two-year history of Parkinson’s disease reports that his steps become progressively shorter and faster while walking. His wife notices that he appears to lean forward and has difficulty stopping once he starts moving. Examination reveals a stooped posture and reduced postural control. Which gait abnormality is most consistent with these findings?

Options:

Correct Answer: Festinating gait

Explanation: Festination describes progressively rapid, short steps associated with impaired gait regulation in parkinsonism. High-stepping and stamping gaits suggest peripheral motor and sensory dysfunction, respectively.

Question: A 61-year-old man reports several years of constipation, reduced ability to smell and disturbed sleep. He has recently developed asymmetric slowness, mild rigidity and reduced right arm swing. His physician suspects Parkinson’s disease. Which interpretation of the earlier symptoms is most appropriate?

Options:

Correct Answer: They may represent prodromal non-motor manifestations

Explanation: Constipation, hyposmia and sleep disturbance can precede motor manifestations of Parkinson’s disease. They are supportive but not independently diagnostic features.

Question: A 66-year-old woman is evaluated for suspected Parkinson’s disease. She has gradually progressive asymmetric bradykinesia, rigidity and resting tremor without pyramidal or cerebellar signs. Routine laboratory testing is unremarkable. Her family requests MRI brain to confirm the diagnosis. Which statement best explains the diagnostic role of MRI in this situation?

Options:

Correct Answer: MRI mainly helps exclude alternative structural causes when indicated

Explanation: Parkinson’s disease is primarily a clinical diagnosis. Structural MRI is not routinely required in a typical presentation but can help exclude alternative causes when atypical findings are present.

Question: A 64-year-old man with recently diagnosed Parkinson’s disease has mild rigidity and slowing that do not significantly interfere with independent daily activities. His physician considers an MAO-B inhibitor for symptomatic treatment. Which pharmacological mechanism explains the potential benefit of this drug class?

Options:

Correct Answer: Reduction of dopamine degradation within the brain

Explanation: MAO-B inhibitors such as rasagiline and selegiline inhibit dopamine breakdown in the central nervous system, increasing dopamine availability and providing modest symptomatic benefit.

Question: A 72-year-old man has Parkinson’s disease with increasing difficulty dressing, bathing and preparing meals. His physician recommends occupational therapy in addition to medication and physiotherapy. What is the principal purpose of occupational therapy in this patient?

Options:

Correct Answer: Improve independence through task adaptation and assistive strategies

Explanation: Occupational therapy focuses on preserving independence in daily activities through adaptive techniques, home modifications and appropriate assistive equipment.

Question: A 69-year-old patient receiving long-term treatment for Parkinson’s disease experiences marked variation in mobility throughout the day. At certain times he walks comfortably, but at other times he becomes almost immobile despite taking medication. These changes are not consistently related to a predictable dose interval. Which motor complication best describes this pattern?

Options:

Correct Answer: Unpredictable on–off fluctuations

Explanation: On–off fluctuations produce transitions between good mobility and severe parkinsonian immobility. Unlike predictable end-of-dose wearing-off, these transitions may occur unpredictably.

Question: A 56-year-old woman presents with progressive difficulty maintaining balance while sitting and standing. Examination shows marked truncal swaying, a broad-based gait and difficulty walking in a straight line. Upper limb finger-to-nose coordination is comparatively preserved. Which cerebellar region is most likely to be predominantly affected?

Options:

Correct Answer: Cerebellar vermis

Explanation: The cerebellar vermis primarily contributes to axial coordination, posture and gait control. Vermian dysfunction produces truncal ataxia and broad-based walking.

Question: A 49-year-old patient has progressive gait unsteadiness and difficulty coordinating hand movements. During conversation, his speech becomes irregular, with uneven separation and emphasis of syllables. Examination also reveals dysmetria and impaired rapid alternating movements. Which speech abnormality is most likely present?

Options:

Correct Answer: Scanning dysarthria

Explanation: Cerebellar dysfunction disrupts the timing and coordination of speech muscles, producing irregular articulation and syllabic emphasis described as scanning or ataxic dysarthria.

Question: A 43-year-old woman experiences sudden episodes of spinning sensation associated with nausea and difficulty maintaining balance. Examination between episodes reveals normal finger-to-nose and heel-to-shin coordination. There is no limb dysmetria or abnormal muscle tone. Which explanation is most consistent with her pattern of imbalance?

Options:

Correct Answer: Vestibular dysfunction affecting equilibrium

Explanation: Episodic vertigo with nausea and preserved limb coordination favors vestibular dysfunction over a primary cerebellar limb ataxia syndrome. Acute continuous vertigo or central neurological signs warrant evaluation for stroke.

Question: A 52-year-old man presents with progressive unsteadiness and slurred speech. Neurological examination shows intention tremor, dysmetria and gait ataxia. The clinician suspects a structural lesion in the posterior fossa. Which investigation is most appropriate to characterize a suspected cerebellar structural abnormality?

Options:

Correct Answer: MRI brain with posterior fossa assessment

Explanation: MRI provides detailed visualization of cerebellar structures and posterior fossa lesions, helping identify tumors, demyelination, degeneration and other structural causes of ataxia.

Question: A 37-year-old man presents with slowly progressive difficulty walking and poor coordination of both hands. His neurological examination reveals gait ataxia, dysarthria and intention tremor. His father and paternal grandmother reportedly experienced similar progressive gait problems. Which diagnostic category should receive particular consideration?

Options:

Correct Answer: Hereditary cerebellar ataxia

Explanation: Progressive cerebellar signs involving multiple generations suggest hereditary ataxia, potentially with autosomal dominant inheritance. Family history helps direct further specialist and genetic evaluation.

Question: A 62-year-old patient has progressive cerebellar dysfunction associated with frequent falls. His examination demonstrates truncal ataxia, impaired coordination and difficulty maintaining balance. The rehabilitation team recommends environmental changes at home. Which recommendation most directly addresses his principal safety problem?

Options:

Correct Answer: Remove household obstacles and improve walking safety

Explanation: Cerebellar ataxia impairs balance and increases fall risk. Removing trip hazards and improving home safety are practical components of rehabilitation alongside gait training and assistive devices.

Question: A 46-year-old woman presents with abrupt onset of irregular involuntary movements affecting the left arm and leg. She has poorly controlled diabetes and is found to have markedly elevated blood glucose without ketoacidosis. Examination demonstrates brief, unpredictable movements rather than sustained abnormal postures. Which diagnostic possibility best explains the relationship between the metabolic abnormality and movement pattern?

Options:

Correct Answer: Hemichorea associated with nonketotic hyperglycemia

Explanation: Severe nonketotic hyperglycemia can disrupt basal ganglia function and produce unilateral choreiform movements. Correcting the metabolic disturbance is an important management priority.

Question: A 44-year-old patient with progressive choreiform movements is found to have Huntington’s disease. His family reports increasing irritability, poor judgment and difficulty completing familiar tasks. Which additional aspect of care is particularly important in developing a comprehensive treatment plan?

Options:

Correct Answer: Assessment of cognition, behavior and psychosocial needs

Explanation: Huntington’s disease causes motor, cognitive and psychiatric manifestations. Comprehensive care therefore includes behavioral assessment, mental health support, rehabilitation and family-centred planning.

Question: A 23-year-old man presents to the emergency department with sudden painful contractions of the facial and neck muscles after receiving an antipsychotic injection. Examination reveals sustained jaw tightening and abnormal neck rotation. There is no loss of consciousness or postictal confusion. Which physiological disturbance most directly explains the movement abnormality?

Options:

Correct Answer: Relative cholinergic predominance following nigrostriatal dopamine blockade

Explanation: Acute dystonia from dopamine receptor-blocking drugs results from altered dopaminergic–cholinergic balance in basal ganglia motor circuits. This explains the therapeutic benefit of anticholinergic treatment.

Question: A 28-year-old woman develops acute dystonia after treatment with metoclopramide. Her symptoms improve following parenteral diphenhydramine administration. Which property of diphenhydramine explains its usefulness in this situation?

Options:

Correct Answer: Central antimuscarinic activity

Explanation: Diphenhydramine has anticholinergic activity that helps correct the relative cholinergic predominance associated with acute dopamine-blocker-induced dystonia.

Question: A 31-year-old man presents with sustained twisting movements of the neck after starting an antipsychotic medication. The clinical team identifies acute drug-induced dystonia. Which additional clinical feature would indicate a potentially life-threatening complication requiring immediate intervention?

Options:

Correct Answer: Inspiratory stridor with respiratory difficulty

Explanation: Laryngeal dystonia can cause airway obstruction and respiratory compromise. Stridor and breathing difficulty require immediate airway assessment and emergency treatment.

Question: A 67-year-old man with Parkinson’s disease reports progressive difficulty speaking loudly during conversations. His family frequently asks him to repeat sentences because his voice has become soft and monotonous. Examination confirms reduced speech volume without evidence of acute stroke. Which intervention is most appropriate to address this functional problem?

Options:

Correct Answer: Referral for speech and language therapy

Explanation: Parkinson’s disease can cause hypophonia through impaired motor control of speech production. Speech and language therapy helps improve voice projection, communication and functional independence.