MRCP Part 2 Category: Neurology

MRCP2-3458

A 42-year-old woman is referred by her primary care physician to the Neurology Clinic. She has a 3-year history of involuntary movements in her hands associated with weight loss. Her husband describes these as ‘piano playing’. More recently she has been emotionally labile with aggressive outbursts and has begun to have some memory problems. She has a family history of ‘Parkinson’s disease’, which affected her maternal grandmother in later life and affects a maternal uncle. Her own mother died in her early thirties in an accident.

Upon examination, she has hypometric saccadic eye movements with broken pursuit movements and some nystagmus at the extremes of gaze. She has continuous fidgety movements of her fingers and arms. There is extrapyramidal rigidity in all four limbs with a shuffling gait. ‘Bedside’ higher function testing reveals some disinhibition with irritability and impaired episodic memory.

Magnetic resonance imaging (MRI) of the brain reveals no significant abnormalities beside some possible cerebral atrophy. Electroencephalogram (EEG) is non-specifically abnormal. Cerebrospinal fluid (CSF) analysis reveals an acellular fluid:

Glucose 4.2 mmol/l (serum 6.8 mmol/l) 2.5–3.9 mmol/l
(two-thirds plasma value)
Protein 0.50 g/dl < 0.45 g/l
14-3-3 protein Negative
S100b Normal range

Choose the test most likely to confirm the diagnosis.

MRCP2-3459

A 75-year-old male presents to the neurology outpatient department with a history of left-sided body weakness that lasted for 30 minutes and resolved completely. He experienced numbness and tingling in the affected area and remained conscious throughout the episode. The patient has a history of hypertension, hypercholesterolemia, smoking, and heavy drinking. He also reports a tremor in both hands that improves after drinking and unsteadiness while walking.

During examination, the patient’s blood pressure is 150/95 mmHg, and a carotid bruit is audible over both sides of the neck. Neurological examination reveals impaired sensations in a glove and stocking distribution. Investigations reveal deep S waves in lead V1-V3 and tall R waves in V4-V6 on ECG and an enlarged cardiac silhouette with flecks of calcification around the aorta on CXR. Carotid artery Doppler studies reveal 85% occlusion in the right external carotid, 50% occlusion in the right internal carotid, 80% occlusion in the left internal carotid, and 60% occlusion in the left external carotid artery.

What is the most appropriate treatment option for this patient?

MRCP2-3460

A 38-year-old Japanese female presents with her second episode of loss of colour vision and significant visual acuity impairment in both eyes. Three days later, she complains of vomiting, acute urinary retention, requiring urinary catheter insertion, and inability to move either leg. On examination, she was unable to correctly name any Ishihara plates. An MRI of her brain and spine demonstrates multiple hyperintense T2 white matter lesions in her spine suggestive of demyelination, one of which extends from C5 to T1. What test confirms the diagnosis?

MRCP2-3429

A 50-year-old woman presents to neurology clinic for follow-up. She was diagnosed with trigeminal neuralgia 6 months ago and started on carbamazepine, but has had limited benefit from the treatment. During her current visit, she reports ongoing pain episodes on the right side of her face and recent episodes on the left side as well. She mentions that her carbamazepine dose was appropriately titrated up by her GP, but the severity of her pain has worsened. Additionally, she reveals that her mother had several episodes of visual loss without medical investigation. On examination, there is no facial nerve weakness but a subjective numbness in the left cheek region is noted. Peripheral neurological examination shows borderline dysdiadochokinesia in the right upper limb and a positive Babinski response in the right lower limb. What is the most suitable investigation for this patient?

MRCP2-3430

As the medical registrar on call, you come across an 81-year-old female inpatient on the same ward who is being treated for community-acquired pneumonia. While reviewing her case, you observe a persistent nodding motion of her head, accompanied by a tremor in both hands, which is more pronounced in the left hand. Upon reviewing her medical history, you discover that she has a history of epilepsy and was prescribed oral phenytoin by her GP four months ago. During the examination, you notice that the hand tremor worsens when her arms are outstretched. However, she performs finger-nose dysmetria testing without any difficulty and has no speech issues. Additionally, there is no cogwheeling observed. Despite the symptoms, the patient seems unconcerned and tells you that she has learned to live with them for years. What is the most likely diagnosis?

MRCP2-3431

A 68 year-old woman presents to hospital after a collapse at home. One week earlier she had seen her own doctor after feeling generally unwell with fever, myalgia, and coryza. These symptoms were attributed to a viral infection and have now resolved. However, for the past few days she has felt unsteady on her feet and has had to hold on to the furniture whilst walking around the house. For the last two days in particular she has also noticed that her vision has deteriorated, and she has been seeing double. Today she tried to hold onto the sofa whilst walking around the room, but misjudged the distance and lost her grip, causing her to fall to the floor. Her daughter who is also present adds that she feels her mothers speech is slurred compared to normal, and has been so for the past three days.

Her past medical history includes hypertension, hypothyroidism, type 2 diabetes, hyperlipidaemia, angina, and recurrent urinary tract infection. She takes ramipril, amlodipine, doxazosin, laevoythyroxine, metformin, gliclazide, simvastatin, atenolol, nicorandil, and nitrofurantoin. She does not smoke but admits to enjoying a glass of sherry on most nights. Usually she is independently mobile, without aids. She lives on her own and is self-caring.

On examination, there are some bruises on the left shoulder where she fell, but no suggestion of any fracture. Observations are normal and she is afebrile. Cardiovascular, respiratory, and abdominal examination is unremarkable. She is fully alert and oriented. Pupils are equal and reactive to light. Eye movements are grossly impaired in all directions. There is no facial asymmetry. Muscle power is normal in all limbs, but finger-nose pointing is impaired and she is unable to walk in a straight line. Reflexes are unobtainable. Sensation is normal.

What is the most likely diagnosis for this 68 year-old woman?

MRCP2-3432

A 32-year-old female presents to clinic with transient visual loss. She reports three episodes over the last few months where her vision ‘turns black’ in both eyes despite being alert. This lasts for a few seconds and is then followed by a unilateral throbbing headache associated with nausea and phonophobia. It is worse on exertion and lasts for a couple of days. On examination her visual acuity is 20/20 bilaterally, her visual fields are normal and fundoscopy is unremarkable.

What is the most likely diagnosis?

MRCP2-3433

A 35-year-old female presents to the neurology clinic with a 6-month history of headaches. She reports experiencing throbbing headaches most days upon waking up, which improve after mobilization but worse with coughing. She has had a few instances of blurred vision upon waking up, but no nausea or vomiting. Her BMI was previously 27 kg/m², but she has since lost weight and now has a BMI of 23 kg/m². She takes paracetamol and ibuprofen regularly for her headaches but is not on any other medications. On examination, there are no focal neurological deficits, and her visual acuity is normal. Mild papilloedema is noted on fundoscopy, and her blood pressure is 125/82 mmHg. Blood tests are unremarkable. What is the most appropriate next step in management?

MRCP2-3434

You are requested to assess a 31-year-old man who was brought to the hospital by ambulance following an assault. According to a witness, he lost consciousness and has since become increasingly drowsy. His current GCS score is 9/15 (E2 V3 M4), making neurological examination challenging. However, his pupils are symmetrical, and he has an extensor right plantar. The CT brain scan below shows a cross-section of his brain.

Based on the information provided, which aspect of the patient’s history is linked to a worse prognosis?

MRCP2-3435

A 55-year-old woman presented to her GP with a four month history of progressive distal sensory loss and weakness of both legs and arms. The weakness and numbness had extended to the elbows and knees.

On examination, cranial nerves and fundoscopy were normal. Examination of the upper limb revealed bilaterally reduced tone and 3/5 power.

Lower limb examination revealed some mild weakness of hip flexion and extension with marked weakness of dorsiflexion and plantarflexion. Both knee and ankle jerks were absent and both plantar responses were mute. There was absent sensation to all modalities affecting both feet extending to the knees.

A lumbar puncture was performed and yielded the following data:

Opening pressure 14 cm H2O (5-18)

CSF protein 0.75 g/L (0.15-0.45)

CSF white cell count 10 cells per ml (<5 cells) CSF white cell differential 90% lymphocytes – CSF red cell count 2 cells per ml (<5 cells) Nerve conduction studies showed multifocal motor and sensory conduction block with prolonged distal latencies. What is the likely diagnosis in this patient?