MRCP Part 2 Category: Neurology

MRCP2-3478

A 15-year-old comes to your neurology clinic complaining of progressive weakness in his lower limbs that has been gradually developing for the past 10 months. He has noticed difficulty keeping up with his peers during physical education classes for the past year and a half, which he initially attributed to his lack of athleticism. However, he now experiences weakness when walking and has particular difficulty rising from a seated position.

During the examination, you observe significantly enlarged calf muscles. Formal power testing reveals 4- out of 5 in bilateral shoulder abduction and adduction, with normal 5 out of 5 distally. Additionally, 4- out of 5 is noted in hip flexion and extension, 4+ in knee flexion and extension, and 5 out of 5 in ankle plantar and dorsiflexion. The weakness is not fatigable and is persistent. Reflexes are present in all areas, and plantar reflexes are downgoing. The patient has no significant medical history, and his family history is unknown as he was adopted. What is the most likely diagnosis?

MRCP2-3463

A 20-year-old male is admitted to the hospital with worsening lower limb weakness. He reports that it started in his ankles, but now he is unable to stand from a squatting position which is abnormal for him. Upon examination, he has reduced power in ankle plantar and dorsiflexion bilaterally as well as some mild weakness in his hip extensors. However, his hand grip strength is normal.

Based on the clinical syndrome and the result of a cerebrospinal fluid (CSF) study, the patient is diagnosed with Guillain-Barre Syndrome (GBS). What treatment should be initiated in the acute setting?

MRCP2-3464

A 60-year-old female presents to the neurology clinic with complaints of tingling and loss of sensation. She had experienced a similar episode five years ago affecting her right upper limb, but had fully recovered. Recently, she has been experiencing a loss of sensation in her left lower limb. She has no past medical history and is not on any regular medications. During the examination, no abnormalities were found. However, an MRI of her brain revealed lesions in the periventricular white matter. What clinical feature of her presentation indicates the poorest prognosis?

MRCP2-3465

A 67-year-old male is brought into the Emergency Department by his concerned daughter, who reports that he has been bedridden for the past 3 days and is unable to recognize her. He has not experienced any recent fevers, cough, dysuria, sore throat, or diarrhea and vomiting prior to becoming unwell. He has a history of Parkinson’s disease and has been undergoing treatment with levodopa-carbidopa for the past 5 years.

On examination, he appears confused and disoriented. He is unable to follow simple commands and is agitated. Neurological examination reveals bradykinesia, rigidity, and tremors in all four limbs. His blood tests are as follows:

Hb 142 g/l
Platelets 280 * 109/l
WBC 8.2 * 109/l

Na+ 139 mmol/l
K+ 4.2 mmol/l
Urea 4.8 mmol/l
Creatinine 70 µmol/l
CRP 3 mg/l
HIV negative
Glucose 6.8 mmol/l

A lumbar puncture was performed:

WBC 12 /mm³
RBC 120 /mm³
Protein 0.65 g/l
Glucose 3.8 mmol/l
PCR and gram staining awaited

What is the most appropriate management step?

MRCP2-3466

A 47-year-old woman has been brought to the Emergency Department by ambulance. Her 22-year-old son found her collapsed on the floor with a note stating that she wished to take her own life. The paramedics have brought all the medication packages that they could find. This included fluoxetine, simvastatin and lorazepam. Previous medical history includes depression with suicidal ideation and a paracetamol overdose 2 years ago that required admission.

Her 20mg fluoxetine package shows three empty slots. Her 1mg lorazepam package shows 20 empty slots.

On assessment of the patient:
A – Airway is supported by the anaesthetist with a bag valve mask.
B – Respiratory rate is being supported up to 12/min. Saturations are maintained at 98% however, the patient desaturates and hyperventilates without assistance.
C – BP 100/70 mmHg, pulse 92 bpm.
D – GCS 8, (E1, M4, V3), pupils 4 mm bilaterally and reactive.

What is the next step in the management of this patient?

MRCP2-3467

A 57-year-old man is brought to the emergency department of a major stroke unit by his wife. She reports that for the last 2 hours, her husband has been struggling to move his right side and speak. The patient has a history of type 2 diabetes mellitus and hypercholesterolemia, for which he takes metformin and atorvastatin respectively. He also recently had a provoked lower limb deep vein thrombosis (DVT) and was started on apixaban. He used to smoke but has quit and drinks occasionally.

Upon examination, the patient has a dense right hemiparesis with expressive dysphasia. He scores 22 on the National Institute of Health Stroke Score (NIHSS).

After a rapid assessment, a CT brain and CT intracranial angiogram are performed, revealing a proximal occlusion within the M2 segment of the middle cerebral artery with no major new ischaemic changes. An MRI head with MR angiography confirms these findings.

What would be the most appropriate intervention for this patient’s presentation?

MRCP2-3468

A 79-year-old male presents to the hyperacute stroke unit with a sudden onset left sided hemiparesis and which is subsequently demonstrated to represent an acute ischaemic infarct in the right middle cerebral artery territory with no haemorrhagic transformation. He was not thrombolysed due to presentation being outside the time window.

As part of his stroke investigations, echocardiogram demonstrates no mural thrombus or regional wall abnormalities and an ejection fraction of 70%. The 24 hour tape recorded no arrhythmias. Carotid Dopplers demonstrate 40% stenosis in the right internal carotid artery, 55% stenosis in the left internal carotid artery. Blood pressure measured 125/75 mmHg.

He takes simvastatin 40 mg nocte and has no known drug allergies. What would be the optimal treatment?

MRCP2-3469

A 51-year-old male presents to the Emergency Department with sudden onset left sided weakness eight hours ago. His partner has brought him into hospital late after finding him collapsed but conscious in his living room after she returned home. His past medical history includes diabetes and hypertension, for which he has been non-compliant with his medications for the past 3 years. On examination, he is drowsy but arousable to minor stimulation. He displays a gaze preference to the left and a right forehead-sparing facial palsy. Power in his left upper and lower limbs score 0/5, right arm and leg score 5/5. He is unaware of his left upper and lower limb being stimulated by painful stimuli. His speech is mildly dysarthric, obeys commands and displays no dysphasic symptoms. His NIHSS score is 18. A hyperacute CT head demonstrates an evolving left middle cerebral artery infarct involving 55% of the left MCA territory. What is the best course of action for management?

MRCP2-3470

A 70-year-old male with a history of ischaemic heart disease and currently taking aspirin presents with a recent TIA causing brief right sided weakness. There is no known atrial fibrillation and routine telemetry has not detected any.

The MRI brain scan shows no evidence of acute stroke and the transthoracic echocardiogram does not reveal any intra-cardiac thrombus. However, a carotid ultrasound study reveals a 70-80% stenosis of the left internal carotid artery.

In addition to ordering a CT carotid angiogram to further investigate the lesion, what would be the next best step in managing this patient?

MRCP2-3471

A 67-year-old man presents with weakness that started 3 hours ago. He reports weakness in his right arm and leg, as well as difficulty finding words. His medical history includes hypertension and hypercholesterolemia. Upon examination, he has grade 4 weakness in his right arm and leg, a right-sided facial droop, and a right homonymous hemianopia. While he can follow complex 3 stage commands, he struggles to name simple objects. You suspect an acute stroke and are considering thrombolysis. You order blood tests and an urgent CT scan. What scoring system will you use to further evaluate this patient?