A 56-year-old female presents to the hospital with recurrent falls and cognitive decline over the past 8 weeks. Her husband reports a possible cough and cold about 3 months ago, but otherwise, she has no significant medical history. On examination, she appears easily startled and has bilateral finger-nose and heel-shin dysmetria, mild postural tremor, and mild speech slurring. Blood tests and a lumbar puncture were performed, with results showing elevated TSH levels and a positive 14-3-3 protein. An EEG demonstrated periodic spikes, and an MRI showed no parenchymal abnormalities. What is the most likely diagnosis?
MRCP2-3500
A 30-year-old woman presents to the neurology clinic with a worsening headache that has been ongoing for a month. The headache is mostly frontal but sometimes moves to the back of her head. It is throbbing in nature and is worst in the morning. She has also been experiencing a thudding sound in her ears. She has no change in vision or photophobia, but the headache has started to make her feel sick. She has no significant medical history and is only taking oral contraceptives. She is obese, a non-drinker, and smokes ten cigarettes per day. On examination, her blood pressure is 165/94 mmHg, and her heart rate is 90/min. Her pupils are equal and reactive, and her visual fields are full to confrontation. Fundoscopy reveals slight blurring of the optic disc margins with a normal retina. The examination of the other cranial nerves reveals no deficits, and her limbs’ tone, power, coordination, and reflexes are all normal. Her BMI is 31, and her blood tests are within normal limits. What is the most appropriate imaging investigation to perform next?
MRCP2-3493
A 29-year-old woman presents with a gradually worsening headache, nausea and vomiting.
The headache started about 3 days ago coming on over about 3-4 hours and is worse on coughing and lying flat. She has been complaining of some nausea and vomiting which she had attributed to some reheated curry she had the night before.
She is usually fit and well but did suffer a spontaneous below-knee deep vein thrombosis (DVT) 2 years ago which was treated with warfarin for 6 months. She has been taking over-the-counter paracetamol and ibuprofen for the headache and currently has a Mirena intrauterine coil in-situ for contraception. She has no known drug allergies.
She currently works as a sales associate. She smokes 10 cigarettes a day and drink 21 units of alcohol a week.
On examination she looks unwell, pale and nauseated. Her blood pressure was 140/98 mmHg, heart rate 100 bpm, oxygen saturations of 98% on air. Her temperature was 36.1 degrees Celsius.
Heart sounds were normal, and her calves soft and non-tender with no evidence of thromboembolism.
Her chest was clear and her abdominal examination was unremarkable.
On neurological examination there was no cranial nerve abnormalities noted. She had normal tone, power, reflexes and sensation in both her upper and lower limbs. Coordination was intact.
Bloods taken by the Emergency Department were as follows:
Na+ 136 mmol/L K+ 3.9 mmol/L Urea 4.8 mmol/L Creatinine 76 µmol/L Hb 12.5 g/dL WBC 11.0 x 10^9/L Platelets 350 x 10^9/L INR 0.9 aPTT 30 seconds LFTs Normal
CT head was performed and reported as normal.
Following this a lumbar puncture was performed:
CSF colour Clear Opening pressure 250 mmH20 White cell count 5.0 x 10^6/L (all lymphocytes) Red cell count 15 x 10^6/L Protein 0.3 g/L Glucose 4.4mmol/L (Serum glucose 5.3mmol/L)
What is the most likely diagnosis?
MRCP2-3494
You review an 85-year old retired teacher in your clinic who has been experiencing numbness in her arms and difficulty walking. Upon examination, you observe reduced sensation on the lateral aspect of her arms and forearms in the anatomical position. There is no muscle wasting on her hands, but she has reduced biceps and supinator reflexes and reduced power bilaterally. Additionally, she has a wide-based scissoring gait and is unable to stand still without support when asked to close her eyes.
This patient lives independently but has been struggling to cope recently. She has a history of hypertension and high cholesterol. What investigation would be most appropriate to diagnose her condition?
MRCP2-3479
A 63 year-old man with a history of osteoarthritis, type II diabetes and mild dementia presents to the neurology clinic with a 2 month history of weakness in his right arm. He has also noticed a decrease in his voice volume and difficulty with tasks such as opening jars and using door handles. His wife has observed him stumbling while walking on two occasions.
During the examination, fasciculations are noted over his right deltoid muscle and wasting of the interossei muscles of the right hand. There is 4/5 strength in right shoulder abduction on the MRC scale. Limb reflexes are absent in the right arm but detectable elsewhere. Coordination is normal, sensation is intact, and Romberg’s test is negative.
What is the most likely diagnosis?
MRCP2-3495
As the medical registrar on-call, you receive a fast-bleep to attend to a patient in the resuscitation room of the Emergency Department. A 28-year-old woman has been admitted with severe breathing difficulties and hypoxia, and has become increasingly drowsy during her time in the department. The emergency physicians have performed arterial blood gases, which show:
Due to the rapidity of her decline, the emergency physicians were only able to obtain a brief history before intubation was required. The patient reported a productive cough over the last few days and mentioned that she was taking tablets for a neurological condition.
Upon examination, you notice that the patient is intubated and maintained on sedation with propofol. She has a well-healed midline sternotomy scar, and coarse crackles are audible in the left mid and lower zones of her chest.
The patient is transferred to the Intensive Care Unit for continued mechanical ventilation and is started on empirical broad-spectrum antibiotics. What additional intervention would most hasten her recovery?
MRCP2-3480
A 28-year-old teacher was referred to the Neurology Clinic with a 4-month history of slurred speech. She had noticed some clumsiness when writing on the board and her handwriting had deteriorated; her colleagues reported that she had seemed withdrawn and forgetful over the past 6 months. Her only past history of note is a tonsillectomy in childhood.
Examination revealed very poor short-term memory and a mini-mental state test of 23/30. She had evidence of cerebellar dysarthria with limb and gait ataxia. EEG revealed diffuse bilateral independent slow (delta) wave activity but no periodic complexes.
What is the most likely diagnosis?
MRCP2-3481
A 24-year-old woman is brought to the emergency department by her mother after being found unresponsive at home. She has a history of epilepsy and has been taking levetiracetam for it. She has also been prescribed diazepam for anxiety and depression in the past. Her mother found several empty packets of diazepam near her.
Upon assessment, her oxygen saturation is 92% on 15L via a non-rebreather mask. Her heart rate is 60/min and her blood pressure is 90/60 mmHg. She is unresponsive to verbal stimuli and only responds to painful stimuli.
What is the most appropriate next step in managing this patient?
MRCP2-3482
A 67-year-old male presents to the neurology outpatient department with a history of recurrent bouts of unsteadiness and vomiting over the last 10 years, with partial resolution. He has also had episodes of visual problems, which he describes as the sudden loss of vision in the right eye, with an almost complete recovery of vision over the course of the next few weeks. He has a history of type 2 diabetes and is hypertensive and is generally non-compliant with his treatment. He is also a smoker with a 50 pack year history.
His medication includes glimepiride 2mg daily and metformin 500mg TDS. He also takes telmisartan 40 mg daily.
On examination, he has nystagmus in the right eye with the fast component towards the right. His gait is ataxic and he has evidence of spasticity in both lower limbs with exaggerated reflexes and bilateral ankle clonus. Fundoscopic examination revealed a pale optic disc.
MRI brain shows diffuse lesions in multiple sites. The report queried demyelinating plaques vs multiple infarcts.
What would be the most appropriate next investigation for this 67-year-old male?
MRCP2-3483
A 25-year-old female presents with a constant diffuse headache, worse on standing than lying down, without neck stiffness or photophobia, but associated with nausea and vomiting. She was recently discharged from the neurology team after being investigated for intermittent headaches over the past 8 months. During her admission, she experienced up to 5 episodes a week, with one episode witnessed by the senior house officer. Her blood tests were unremarkable, and a CT head showed no intracranial lesions. A lumbar puncture was performed, and the patient self-discharged with no immediate complications. However, during this second admission, an MRI head scan revealed significant diffuse meningeal enhancement and bilateral shallow subdural haemorrhages. What is the appropriate treatment for this 25-year-old female?