MRCP Part 2 Category: Neurology

MRCP2-3448

A 54-year-old man presents to the neurology clinic with a 6-month history of loss of dexterity and new-onset dysphagia. The patient reports a history of hypertension for which he takes amlodipine 5mg once daily with no family history of note, he is a non-smoker and drinks 3 glasses of wine per week.

Systems review reveals no history of rashes, joint pain, swelling or stiffness, no fevers, and no weight loss. A recent endoscopy showed no obvious abnormalities to explain the patient’s dysphagia.

Physical examination demonstrates asymmetrical wasting of the deltoids with noticeable weakness of wrist flexion bilaterally (MRC grading 4/5).

Co-ordination is normal on the assessment of the upper and lower limbs, which decreased ankle jerk reflexes bilaterally. Plantars are downgoing bilaterally. Cranial nerve assessment is unremarkable, however, a bedside swallow assessment is suggestive of a delayed oropharyngeal phase.

Bloods tests ordered by the neurologist demonstrate:
Hb 140 g/L Male: (135-180)
Female: (115 – 160)
Platelets 220 * 109/L (150 – 400)
WBC 5.0 * 109/L (4.0 – 11.0)

Calcium 2.26 mmol/L (2.1-2.6)
Phosphate 1.04 mmol/L (0.8-1.4)
Magnesium 0.9 mmol/L (0.7-1.0)
Thyroid stimulating hormone (TSH) 0.6 mU/L (0.5-5.5)
Free thyroxine (T4) 10.1 pmol/L (9.0 – 18)
Creatine kinase 1000 U/L (35 – 250)

What is the most likely diagnosis for this 54-year-old man?

MRCP2-3449

An 80-year-old male presents with progressive weakness in his arms. He visited his GP 6 months ago complaining of weakness in his right wrist and was diagnosed with carpal tunnel syndrome. However, his condition has worsened over the past few months, with increasing weakness in his right wrist and elbow, as well as his left wrist. He reports no changes in sensation, speech, or swallowing. On examination, both hands show significant muscle wasting and fasciculations, with muted reflexes and negative Hoffman’s sign. Sensory examination is unremarkable, and the patient is unable to perform the finger-nose examination. MRI imaging of the head and spine shows no significant lesions, while nerve conduction studies reveal multiple focal areas of demyelination and motor neuropathic blocks.

What is the most appropriate course of management for this patient?

MRCP2-3450

A 35-year-old teacher with controlled hypertension complains of increasing weakness and fatigue, particularly in the afternoons. She has noticed occasional double vision and her colleagues have commented that her eyelids appear droopy at times. Her symptoms seem to worsen as the day goes on. She reports being a non-smoker and drinking alcohol only occasionally.
On examination, there is mild ptosis of the right eye. After sustained upward gaze for 30 seconds, there is complete ptosis of the right eye and partial ptosis of the left eye. There is no diplopia in the primary position. Eye movement examination reveals incomplete abduction of both eyes, with variable diplopia on horizontal and vertical pursuit. Limb examination shows generalized weakness, which is more pronounced proximally. Reflexes are symmetrical with flexor plantar responses. There is no sensory loss.
Which diagnostic investigation would be most helpful in this case?

MRCP2-3451

A 64-year-old man presents to the Elderly Care Clinic for review after retiring due to being unable to cope with the pace of his job. His wife is concerned about his increasing withdrawal, apathy, and mobility problems, including three falls at home and incontinence of urine. He has a past medical history of hypertension and an inferior myocardial infarction. On examination, he has a flat affect, unsteady gait, small shuffling steps, a minor tremor, increased muscle rigidity, and paralysis of upward gaze. His blood pressure is 145/72 mmHg, and pulse 85 bpm with a 20 mmHg postural drop on standing. Investigations reveal normal values for haemoglobin, white cell count, platelets, sodium, potassium, creatinine, glucose, and thyroid-stimulating hormone. Chest X-ray and computed tomography head are unremarkable. What is the most likely diagnosis?

MRCP2-3452

A 50-year-old male is discovered confused on the street by a police officer. Medical records indicate that he is a known type 2 diabetic with a history of non-attendance to clinic and poor adherence to medications. He has also been admitted to the hospital twice before, 2 and 10 years ago, for alcohol withdrawal. During the examination, the patient is disoriented in time and place, scoring 0 out of 10 on the abbreviated mental test. He is able to comply with commands to lift his upper and lower limbs during his neurological examination, and all reflexes are present. However, he fails to track your finger with his eyes during the cranial nerve examination. His gait is significantly ataxic, as evidenced by his attempt to walk to the bathroom against medical and nursing advice. His blood sugar level is currently pending. What is the diagnosis?

MRCP2-3453

A 33 year old man presents with left lower limb weakness for the past four weeks. Over the past week his condition has deteriorated significantly. He has also experienced a loss of appetite and has lost six kilograms in the last two months. Additionally, he has reported recurrent nosebleeds during this time.

Despite using nicotine transdermal patches and varenicline for three months, he is now no longer actively smoking. He is married and works as a salesman for a pharmaceutical company. In the past year, he has traveled to many destinations around the world as part of his job.

During examination, he appeared unwell and was mentally slow in understanding commands. The power in his left leg was grade 2 for all muscle groups, while tone, sensation, coordination, and reflexes were all normal. No abnormalities were detected in other systems. The following investigations were ordered:

– Hb: 10g/dl
– Platelets: 10 * 10^9/l
– WBC: 4* 10^9/l
– Neutrophils: 60%
– Lymphocytes: 34%
– Na+: 135 mmol/l
– K+: 4 mmol/l
– Creatinine: 95 µmol/l
– Urea: 4 mmol/l

Urine analysis: Clear

An MRI of his brain showed bilateral multiple hyperintense demyelinating lesions involving subcortical areas without any mass effect.

What is the most appropriate course of action?

MRCP2-3454

A 44 year-old man is brought to the hospital after being found wandering aimlessly, unable to recall his identity or how he ended up there. Following a collateral history, he is referred to the neurologists for further evaluation.

Over the past few months, he has been experiencing increasing forgetfulness and clumsiness, along with progressively odd behavior. His speech has become muddled, and he struggles with everyday tasks. Others have observed that he has become quite fidgety, and he sometimes drops things unintentionally.

Previously, he was healthy and served as the primary caregiver for his father, who has motor neuron disease. His sister, who previously assisted him in caring for their father, recently died in a car accident.

At the age of 20, he underwent extensive surgical resection of a large parafalcine meningioma that was discovered after a chronic headache investigation. Since the operation, he has been free of headaches.

During the examination, he is entirely disoriented in terms of time, place, and person. His gait is broad-based and uncoordinated, and you observe several shock-like jerks of his arms. Tone, power, reflexes, and sensation are otherwise normal, and cranial nerve examination is unremarkable.

What is the most probable diagnosis?

MRCP2-3455

A 65-year-old woman is brought to the Geriatrics outpatient clinic by her son. He is extremely concerned and she has been displaying some very odd behaviour and has had some weakness in her lower limbs.
She reports that about a year ago she and her family noticed that their mother’s house was beginning to become cluttered as she had become unable to manage her belongings. They had also had complaints from neighbors who felt their mother’s behavior was often rude and disinhibited, laughing or crying at inappropriate times. She had developed a ‘sweet tooth’ and would hoard such items, eating little else. The son reported that over the last few weeks he had noticed his mother’s speech sounded different and she had difficulty getting out of her chair.
She had previously been fit and well, with no past medical history and took no medications.
On examination, the patient’s speech has a nasal quality and she has an impaired swallow with tongue fasciculations. The remainder of the cranial nerve examination is normal and there is no papilloedema. She has proximal limb weakness of 4/5 bilaterally and fasciculations of her left quadriceps. Her reflexes are brisk. Her sensory exam is normal. Her mini-mental state examination (MMSE) scores 28/30, with some subtle word-finding difficulties.
What is the most likely diagnosis?

MRCP2-3456

A 45-year-old secretary presents to the Outpatient Clinic with complaints of sharp, burning sensations over the right side of his face. He experiences episodes that last from a few seconds to approximately 2 minutes and occur up to 50 times a day with no symptoms in between. The pain is exacerbated by eating, speaking, and washing his face. A thorough neurological examination reveals no cranial nerve or limb signs, intact corneal reflex on both sides, and intact sensation on both sides of the face. The following investigations were conducted: Haemoglobin (Hb), White cell count (WCC), Platelets (PLT), Sodium (Na+), Potassium (K+), Creatinine (Cr), Mean corpuscular volume (MCV), Urea, Corrected calcium (Ca2+), Thyroid-stimulating hormone (TSH), T4, Vitamin B12, Folate, and Glucose. The results showed that the patient’s Hb, MCV, and Vitamin B12 levels were low. Which of the following treatments is likely to be of most benefit?

MRCP2-3457

A 45-year-old man presents to the Emergency Department with a 2-week history of increasing drowsiness and confusion. According to his wife, he had been complaining of fatigue and had been spending most of his time in bed for the past week. He stopped going to work a week ago. This morning, his wife had difficulty waking him up, and when she did, he seemed confused and had slurred speech.

The patient has a history of epilepsy and bipolar disorder. On examination, he only responds to painful stimuli. His vital signs are normal, and his chest and abdomen exams are unremarkable. Blood tests reveal:

Hb 152 g/l Na+ 139 mmol/l Bilirubin 18 µmol/l
Platelets 278 * 109/l K+ 4.3 mmol/l ALP 117 u/l
WBC 8.1 * 109/l Urea 5.2 mmol/l ALT 19 u/l
Neuts 5.4 * 109/l Creatinine 93 µmol/l γGT 48 u/l
Lymphs 1.8 * 109/l Albumin 41 g/l
Eosin 0.2 * 109/l Ammonia 197 µmol/l

The patient’s wife mentions that his medications were recently changed by his GP. What medication change is most likely responsible for his symptoms?