ADVANCED CLINICAL
PHARMACOLOGY & NEUROLOGY
BOARD REVIEW
A Comprehensive 200-Question Examination with Detailed Rationales on Movement
Disorders, Neuropharmacology, and Psychopharmacology
Institution of Advanced Medical and Pharmacological Studies
October 2026
,Comprehensive 200-Question Examination
Question 1
Question 1: A 60-year-old male with Parkinson's disease develops visual hallucinations and paranoid
delusions attributed to his dopaminergic therapy. Which atypical antipsychotic with minimal
extrapyramidal side effects is preferred?
A) Haloperidol
B) Pimavanserin
C) Risperidone
D) Olanzapine
Answer & Rationale: Correct Answer: B. Pimavanserin is an inverse agonist and antagonist
selectively targeting 5-HT2A receptors, making it FDA-approved for Parkinson's disease psychosis
without worsening motor symptoms because it lacks D2 receptor blockade.
Question 2
Question 2: A patient receiving carbidopa-levodopa develops involuntary choreiform movements of the
face and limbs during peak plasma concentration times. What is the underlying pathophysiological
mechanism of these dyskinesias?
A) Acetylcholine excess in the striatum
B) Pulsatile post-synaptic dopaminergic stimulation in the basal ganglia
C) Glutamatergic hypoactivity at the NMDA receptor
D) Noradrenergic depletion in the locus coeruleus
Answer & Rationale: Correct Answer: B. Peak-dose dyskinesias result from intermittent, pulsatile
stimulation of striatal dopamine receptors caused by the short half-life of oral levodopa alongside
progressive degeneration of presynaptic dopaminergic terminals.
Question 3
Question 3: A 72-year-old man presents with progressive symmetric rigidity, early postural instability
with frequent falls within the first year of symptom onset, and vertical supranuclear gaze palsy. What is
the most likely diagnosis?
A) Idiopathic Parkinson's disease
B) Progressive supranuclear palsy (PSP)
C) Multiple system atrophy (MSA)
D) Corticobasal degeneration
Answer & Rationale: Correct Answer: B. Progressive supranuclear palsy (PSP) is a tauopathy
characterized by early postural instability, falls, symmetrical axial rigidity, and characteristic vertical
gaze palsy (specifically downward gaze impairment).
,Question 4
Question 4 (Clinical Scenario #4): A 54-year-old patient presents for evaluation of progressive
neurological and pharmacological management. A 68-year-old man with advanced Parkinson's disease on
levodopa/carbidopa presents with vivid nocturnal visual hallucinations. His motor symptoms are well-
controlled. What is the most appropriate initial pharmacological adjustment?
A) Immediately discontinue levodopa
B) Add haloperidol 5 mg daily
C) Reduce or taper adjunctive dopamine agonists (e.g., pramipexole)
D) Double the levodopa dose
Answer & Rationale: Correct Answer: C. When managing Parkinson's disease psychosis, the first
step is to taper and discontinue non-dopaminergic adjuncts (anticholinergics, amantadine) followed
by reducing dopamine agonists, as these agents carry the highest psychiatric side effect profile before
modifying levodopa.
Question 5
Question 5 (Clinical Scenario #5): A 55-year-old patient presents for evaluation of progressive
neurological and pharmacological management. A 55-year-old woman with idiopathic Parkinson's disease
experiences unpredictable 'off' periods characterized by sudden freezing of gait. Which adjunct
medication specifically targets reducing 'off' time by inhibiting monoamine oxidase type B?
A) Selegiline
B) Entacapone
C) Benztropine
D) Quetiapine
Answer & Rationale: Correct Answer: A. Selegiline and rasagiline are selective MAO-B inhibitors
that reduce dopamine breakdown in the striatum, ameliorating 'off' episodes. Entacapone is a COMT
inhibitor, while benztropine is an anticholinergic used for tremor.
Question 6
Question 6 (Clinical Scenario #6): A 56-year-old patient presents for evaluation of progressive
neurological and pharmacological management. A 72-year-old man presents with progressive symmetric
rigidity, early postural instability with frequent falls within the first year of symptom onset, and vertical
supranuclear gaze palsy. What is the most likely diagnosis?
A) Idiopathic Parkinson's disease
B) Progressive supranuclear palsy (PSP)
C) Multiple system atrophy (MSA)
D) Corticobasal degeneration
Answer & Rationale: Correct Answer: B. Progressive supranuclear palsy (PSP) is a tauopathy
characterized by early postural instability, falls, symmetrical axial rigidity, and characteristic vertical
gaze palsy (specifically downward gaze impairment).
, Question 7
Question 7 (Clinical Scenario #7): A 57-year-old patient presents for evaluation of progressive
neurological and pharmacological management. A 60-year-old male with Parkinson's disease develops
visual hallucinations and paranoid delusions attributed to his dopaminergic therapy. Which atypical
antipsychotic with minimal extrapyramidal side effects is preferred?
A) Haloperidol
B) Pimavanserin
C) Risperidone
D) Olanzapine
Answer & Rationale: Correct Answer: B. Pimavanserin is an inverse agonist and antagonist
selectively targeting 5-HT2A receptors, making it FDA-approved for Parkinson's disease psychosis
without worsening motor symptoms because it lacks D2 receptor blockade.
Question 8
Question 8 (Clinical Scenario #8): A 58-year-old patient presents for evaluation of progressive
neurological and pharmacological management. A patient receiving carbidopa-levodopa develops
involuntary choreiform movements of the face and limbs during peak plasma concentration times. What
is the underlying pathophysiological mechanism of these dyskinesias?
A) Acetylcholine excess in the striatum
B) Pulsatile post-synaptic dopaminergic stimulation in the basal ganglia
C) Glutamatergic hypoactivity at the NMDA receptor
D) Noradrenergic depletion in the locus coeruleus
Answer & Rationale: Correct Answer: B. Peak-dose dyskinesias result from intermittent, pulsatile
stimulation of striatal dopamine receptors caused by the short half-life of oral levodopa alongside
progressive degeneration of presynaptic dopaminergic terminals.
Question 9
Question 9 (Clinical Scenario #9): A 59-year-old patient presents for evaluation of progressive
neurological and pharmacological management. A 72-year-old man presents with progressive symmetric
rigidity, early postural instability with frequent falls within the first year of symptom onset, and vertical
supranuclear gaze palsy. What is the most likely diagnosis?
A) Idiopathic Parkinson's disease
B) Progressive supranuclear palsy (PSP)
C) Multiple system atrophy (MSA)
D) Corticobasal degeneration
Answer & Rationale: Correct Answer: B. Progressive supranuclear palsy (PSP) is a tauopathy
characterized by early postural instability, falls, symmetrical axial rigidity, and characteristic vertical
gaze palsy (specifically downward gaze impairment).
PHARMACOLOGY & NEUROLOGY
BOARD REVIEW
A Comprehensive 200-Question Examination with Detailed Rationales on Movement
Disorders, Neuropharmacology, and Psychopharmacology
Institution of Advanced Medical and Pharmacological Studies
October 2026
,Comprehensive 200-Question Examination
Question 1
Question 1: A 60-year-old male with Parkinson's disease develops visual hallucinations and paranoid
delusions attributed to his dopaminergic therapy. Which atypical antipsychotic with minimal
extrapyramidal side effects is preferred?
A) Haloperidol
B) Pimavanserin
C) Risperidone
D) Olanzapine
Answer & Rationale: Correct Answer: B. Pimavanserin is an inverse agonist and antagonist
selectively targeting 5-HT2A receptors, making it FDA-approved for Parkinson's disease psychosis
without worsening motor symptoms because it lacks D2 receptor blockade.
Question 2
Question 2: A patient receiving carbidopa-levodopa develops involuntary choreiform movements of the
face and limbs during peak plasma concentration times. What is the underlying pathophysiological
mechanism of these dyskinesias?
A) Acetylcholine excess in the striatum
B) Pulsatile post-synaptic dopaminergic stimulation in the basal ganglia
C) Glutamatergic hypoactivity at the NMDA receptor
D) Noradrenergic depletion in the locus coeruleus
Answer & Rationale: Correct Answer: B. Peak-dose dyskinesias result from intermittent, pulsatile
stimulation of striatal dopamine receptors caused by the short half-life of oral levodopa alongside
progressive degeneration of presynaptic dopaminergic terminals.
Question 3
Question 3: A 72-year-old man presents with progressive symmetric rigidity, early postural instability
with frequent falls within the first year of symptom onset, and vertical supranuclear gaze palsy. What is
the most likely diagnosis?
A) Idiopathic Parkinson's disease
B) Progressive supranuclear palsy (PSP)
C) Multiple system atrophy (MSA)
D) Corticobasal degeneration
Answer & Rationale: Correct Answer: B. Progressive supranuclear palsy (PSP) is a tauopathy
characterized by early postural instability, falls, symmetrical axial rigidity, and characteristic vertical
gaze palsy (specifically downward gaze impairment).
,Question 4
Question 4 (Clinical Scenario #4): A 54-year-old patient presents for evaluation of progressive
neurological and pharmacological management. A 68-year-old man with advanced Parkinson's disease on
levodopa/carbidopa presents with vivid nocturnal visual hallucinations. His motor symptoms are well-
controlled. What is the most appropriate initial pharmacological adjustment?
A) Immediately discontinue levodopa
B) Add haloperidol 5 mg daily
C) Reduce or taper adjunctive dopamine agonists (e.g., pramipexole)
D) Double the levodopa dose
Answer & Rationale: Correct Answer: C. When managing Parkinson's disease psychosis, the first
step is to taper and discontinue non-dopaminergic adjuncts (anticholinergics, amantadine) followed
by reducing dopamine agonists, as these agents carry the highest psychiatric side effect profile before
modifying levodopa.
Question 5
Question 5 (Clinical Scenario #5): A 55-year-old patient presents for evaluation of progressive
neurological and pharmacological management. A 55-year-old woman with idiopathic Parkinson's disease
experiences unpredictable 'off' periods characterized by sudden freezing of gait. Which adjunct
medication specifically targets reducing 'off' time by inhibiting monoamine oxidase type B?
A) Selegiline
B) Entacapone
C) Benztropine
D) Quetiapine
Answer & Rationale: Correct Answer: A. Selegiline and rasagiline are selective MAO-B inhibitors
that reduce dopamine breakdown in the striatum, ameliorating 'off' episodes. Entacapone is a COMT
inhibitor, while benztropine is an anticholinergic used for tremor.
Question 6
Question 6 (Clinical Scenario #6): A 56-year-old patient presents for evaluation of progressive
neurological and pharmacological management. A 72-year-old man presents with progressive symmetric
rigidity, early postural instability with frequent falls within the first year of symptom onset, and vertical
supranuclear gaze palsy. What is the most likely diagnosis?
A) Idiopathic Parkinson's disease
B) Progressive supranuclear palsy (PSP)
C) Multiple system atrophy (MSA)
D) Corticobasal degeneration
Answer & Rationale: Correct Answer: B. Progressive supranuclear palsy (PSP) is a tauopathy
characterized by early postural instability, falls, symmetrical axial rigidity, and characteristic vertical
gaze palsy (specifically downward gaze impairment).
, Question 7
Question 7 (Clinical Scenario #7): A 57-year-old patient presents for evaluation of progressive
neurological and pharmacological management. A 60-year-old male with Parkinson's disease develops
visual hallucinations and paranoid delusions attributed to his dopaminergic therapy. Which atypical
antipsychotic with minimal extrapyramidal side effects is preferred?
A) Haloperidol
B) Pimavanserin
C) Risperidone
D) Olanzapine
Answer & Rationale: Correct Answer: B. Pimavanserin is an inverse agonist and antagonist
selectively targeting 5-HT2A receptors, making it FDA-approved for Parkinson's disease psychosis
without worsening motor symptoms because it lacks D2 receptor blockade.
Question 8
Question 8 (Clinical Scenario #8): A 58-year-old patient presents for evaluation of progressive
neurological and pharmacological management. A patient receiving carbidopa-levodopa develops
involuntary choreiform movements of the face and limbs during peak plasma concentration times. What
is the underlying pathophysiological mechanism of these dyskinesias?
A) Acetylcholine excess in the striatum
B) Pulsatile post-synaptic dopaminergic stimulation in the basal ganglia
C) Glutamatergic hypoactivity at the NMDA receptor
D) Noradrenergic depletion in the locus coeruleus
Answer & Rationale: Correct Answer: B. Peak-dose dyskinesias result from intermittent, pulsatile
stimulation of striatal dopamine receptors caused by the short half-life of oral levodopa alongside
progressive degeneration of presynaptic dopaminergic terminals.
Question 9
Question 9 (Clinical Scenario #9): A 59-year-old patient presents for evaluation of progressive
neurological and pharmacological management. A 72-year-old man presents with progressive symmetric
rigidity, early postural instability with frequent falls within the first year of symptom onset, and vertical
supranuclear gaze palsy. What is the most likely diagnosis?
A) Idiopathic Parkinson's disease
B) Progressive supranuclear palsy (PSP)
C) Multiple system atrophy (MSA)
D) Corticobasal degeneration
Answer & Rationale: Correct Answer: B. Progressive supranuclear palsy (PSP) is a tauopathy
characterized by early postural instability, falls, symmetrical axial rigidity, and characteristic vertical
gaze palsy (specifically downward gaze impairment).
