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Neurology Residency Interview Questions and Answers

Medical Residency Application & Interview Preparation Specialists

Interviews for a Neurology Residency can require a real depth of knowledge and robust attributes. Here, we present 10 questions and answers suitable for candidates to Neurology Residency in the US. Further questions can be found in our Medical Residency Interview Question Bank

Cranial Nerves

Tell me about CN IX.

CN IX is the glossopharyngeal nerve. It has all of sensory, motor, and parasympathetic functions. It begins in the medulla oblongata and terminates in the pharynx. Branches are tympanic, tonsillar, stylopharyngeal, carotid, lingual, pharyngeal, and communicating branch to CN X. Motor innervation is provided to the stylopharyngeus muscle, which elevates the pharynx and larynx.

Tell me about CN III.

CN III, the oculomotor nerve, has three motor functions: innervation to the pupil and lens (autonomic and parasympathetic), innervation to the upper eyelid (somatic), innervation of the eye muscles allowing for visual tracking (somatic). The nerve originates from the oculomotor nucleus and accessory parasympathetic nucleus. Muscles controlled include the levator palpebrae superioris, super, medial and inferior rectus muscles, inferior oblique muscle, ciliary muscle, and sphincter pupillae. 

Tell me about CN II.

CN II is the optic nerve, and passes from the retina to the optic chiasm. Action potentials are generated in the rods and cones of the retina, which in turn then converge at the optic disc and continue through the optic nerve. The optic nerve lies above the cavernous sinus. Fibres from the temporal retinal fields stay on the same side, whilst fibre from the nasal fields will swap sides and cross. THis means that after the optic chiasm, the right optic tract contains the right retinal fields of both eyes, and the left optic tract contains the left retinal fields of both eyes. The optic tract reaches the LGN, which passes information to the primary visual cortex by the dorsal optic radiations. 

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Clinical Knowledge: Investigations and Imaging

What imaging investigations would be warranted in a patient with a severe, isolated headache and no abnormal neurology in primary care? What if they had abnormal neurology?

No imaging investigations would be required for this patient, as the probability of finding serious pathology in such a case (non-emergency, isolated headache, no abnormal neurology) is roughly equivalent to that in a patient without a headache (i.e. very low). Thus there is no clinical benefit, but unnecessary radiation exposure. If they presented with abnormal neurology, then imaging would be required – the imaging of choice would be a CT scan. 

What investigations would you perform in suspected MS?

Lab investigations will allow one to rule out infection (FBC), inflammatory processes (CRP), hepatic pathology seen in MS mimics (LFTs), electrolyte disturbance (U&Es), sarcoidosis (calcium) and thyroid functions will ensure that hypothyroidism is not a concern. B12 and HIV serology will also be assessed.

The primary investigation is then MRI of the brain and spinal cord with gadolinium contrast. Lesions appear as T2 hyper-intense white matter plaques. Lumbar puncture for CSF analysis may also be used, with typical findings including oligoclonal bands of immunoglobulin, and high protein content.

Tell me about the typical symptoms of optic neuritis, and what you might find on examination.

Symptoms of ON will typically include acute or subacute unilateral visual loss, with visual acuity ranging from 6/6 to a total inability to detect light; peri-ocular and retrobulbar pain, which is present in more than 90% of cases and exacerbated by eye movements; photopsias; reduced sensitivity to contrast and colour; visual field loss (which may occur in any pattern). Vision will worsen over hours or days, and recovery will start within two weeks whether treatment is provided or not. Particular points to note on exam include a positive RAPD, and swelling of the optic nerve on fundoscopy (in some cases). 

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Knowledge of Disease

What are the four main groups of MS or MS-like syndromes?

Clinically isolated syndrome is an otherwise unexplained clinical episode of neurological dysfunction, and radiologically isolated is evidence of white matter pathology with clinical symptoms absent – CIS and RIS make up category one. Both syndromes are suggestive or MS, but do not technically constitute MS.

Relapsing-remitting MS is the most common form of the disease, and covers 85% of patients. Neurological attacks last for 24 hours or greater, and symptoms are relieved after the attack. Attacks are unpredictable.

Secondary progressive MS follows RRMS and consists of a steady decline without remission.

Primary progressive MS is a progressively worsening form of the disease that has no remission at any stage.

Tell me about the risk factors and typical history of Parkinson’s Disease.

Parkinson’s is idiopathic, with the cause of the loss of dopaminergic cells not yet being understood. There is some genetic association, and male sex and increasing age are also known to be risk factors for the condition. Smoking appears to be protective.

Typical symptoms from history will include slow, stiff movements, tremor and instability, and reduced dexterity; low mood, anxiety or apathy; constipation, hyperhidrosis, and other autonomic manifestations; sleep disturbance, and anosmia. There may also be cognitive decline, sleep behaviour disorders reported by family members, or altered handwriting (micrographia). Drug history must be covered to exclude drug-induced parkinsonism. 

Tell me about the aetiology and clinical features of Alzheimer’s.

Alzheimer’s is caused by the buildup of amyloid plaques (beta-amyloid clumps) and neurofibrillary tangles (mostly made of tau protein). Buildup leads to reduced transfer of information and the death of brain cells. Alzheimer’s typically develops after the age of 60, and can affect all areas of the brain. This means that varied functions can be lost, although the most common presenting symptom is memory loss. There will typically be changes in the ability to plan, reason, talk and orientate. Note that there is no stepwise progression here, unlike in vascular dementia. Progression is instead continuous. 

What are cluster headaches?

Cluster headaches are the most common form of trigeminal autonomic cephalgia. They affect only 0.1% of the population, and are one of the most severe forms of headache. A cluster headache is a short-lasting unilateral headache with at least one ipsilateral autonomic symptom (e.g. nasal congestion, lacrimation). The headaches typically occur around the same time of day, often at night, and attacks are typically episodic, with daily attacks for some weeks, then remission for months or years. Risk factors include being male, age greater than 30, consuming alcohol, prior brain surgery or trauma to the head, and family history. Conjunctival injection or lacrimation will be seen in 90%, nasal congestion or rhinorrhea in 84%, and eyelid edema or facial swelling in 59% of patients. Treatment is with 100% oxygen therapy, or triptans. 

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