A 65-year-old woman visits her GP complaining of progressive numbness and difficulty walking. Her daughter, who accompanies her, reports that she has been exhibiting strange behavior for the past few months. The patient has a history of ileal resection for Crohn’s disease that was resistant to treatment, nine years ago.
Upon laboratory testing, the patient’s haematocrit and mean corpuscular volume were found to be low. Additionally, macrocytic red blood cells with hypersegmented neutrophils were observed in the blood smear analysis.
What is the most probable cause of the patient’s symptoms?
MRCP2-3437
A 65-year-old woman presents to neurology clinic following a referral from her GP due to intermittent facial pain. The patient first noticed symptoms approximately 9 months ago, with the initial attack occurring while attending a fireworks display with her grandchildren. The pain is described as a severe sewing sensation affecting the right side of her face, lasting for 1-2 minutes before resolving completely. Since the onset, the patient reports experiencing at least one attack on most days, with the frequency seeming to increase over time. Although the patient has experienced a blocked nose and sweating during some episodes, these symptoms are not as concerning as the severe pain. The patient denies any other symptoms and is otherwise in good health, with no recent history of weight loss. There is no family history of neurological disease.
During the consultation, the patient experiences a new episode of pain, allowing for further examination. Conjunctival injection and slight eyelid edema of the right eye are noted, along with profuse sweating on the right side of the face. The patient confirms the onset of a blocked nose sensation at the start of the pain.
What is the most likely diagnosis responsible for the patient’s symptoms?
MRCP2-3438
A 78-year-old male presents to the clinic with a 9-month history of progressive confusion, unsteadiness on his feet, and new urinary incontinence. He has a minimal past medical history and takes ramipril for hypertension. On examination, he has a wide-based and ataxic gait, and his abbreviated mental test score is 3/10. The mini-mental state examination scores 16/30. A CT head shows no acute haemorrhages or infarcts, and an MRI reveals large ventricles with periventricular white matter changes. Lumbar puncture shows acellular cerebrospinal fluid with no organism growth, and the opening pressure is 16 cm H20. A CSF infusion test is arranged, which demonstrates raised CSF outflow resistance. What is the most appropriate treatment for this patient?
MRCP2-3439
A 78-year-old presents to the hospital with muscle cramps, fevers, and passing dark urine. The patient has a history of Parkinson’s disease and takes Sinemet 125 five times a day. Due to unforeseen circumstances, the patient’s daughter has been unable to pick up his medication for the past 5 days, resulting in the patient not taking his PD meds for 3 days. The patient’s blood pressure is fluctuating between 77/52 mmHg to 150/88mm Hg. Upon examination, the patient has a temperature of 39.2 degrees, quiet but present heart sounds, and unremarkable chest auscultation. The patient has rigid muscles in all four limbs, no obvious superficial evidence of head injury, and new confusion with an abbreviated mental test score of 0/10. The patient is started on intravenous fluids, intravenous broad-spectrum antibiotics, catheterized, and a nasogastric tube is inserted to administer his regular medications. What is the underlying diagnosis?
MRCP2-3440
A 28 year-old woman presents to the neurology clinic with complaints of headache and visual disturbance. She recently moved to the United States from Ghana. Her symptoms started about a month ago, shortly after giving birth to her first child. She experiences a dull frontal headache that is most severe in the mornings and when coughing or straining, as well as brief episodes of vision darkening. She was previously diagnosed with idiopathic intracranial hypertension by a doctor in Ghana and is currently taking acetazolamide 250mg twice daily as her only medication.
During the examination, her visual fields are significantly constricted, and the right blind spot is enlarged. Bilateral papilloedema is worse on the right, as seen on fundoscopy. The rest of the neurological examination is unremarkable. Her BMI is 18 kg/m². A plain computed tomography of the brain shows no abnormalities.
As she is leaving the clinic, she mentions that she has been experiencing pins and needles in her hands and feet.
What is the most appropriate course of action?
MRCP2-3441
A 49-year-old man presents to the emergency department after experiencing a 3-minute tonic-clonic seizure. He has no history of epilepsy and has never had a seizure before. He has been complaining of intermittent headaches and fevers for the past 10 days. The patient’s medical history includes hypertension, which is managed with amlodipine, ramipril, and indapamide once daily.
Upon examination, the patient is drowsy with a GCS of 13 (E3V4M6). His chest and heart sounds are normal, and his abdomen is soft and non-tender. The patient’s temperature is recorded as 38.1ºC.
A contrast-enhanced MRI scan is performed, as shown below:
Based on the likely diagnosis, what is the most probable causative pathogen?
MRCP2-3442
A 36-year-old female presents to the Emergency Department with a three-day history of increasing weakness in the left arm and reduced visual acuity in the left eye. She was diagnosed with relapsing-remitting multiple sclerosis three years ago and is compliant with her fingolimod maintenance therapy.
Upon examination, she exhibits weakness in wrist extension and finger abduction in the left hand, and her left eye’s visual acuity is measured at 6/24 with a corresponding reduction in colour saturation. Her blood tests are unremarkable, and her white cell count is normal. However, her MRI scan reveals two new enhancing lesions in the right pericallosal region.
What is the appropriate acute management for this patient?
MRCP2-3443
A 58-year-old man presents to the emergency department after collapsing 2 hours ago. His partner witnessed the fall and reported that he has not been able to move his right arm and leg since. The patient had no prior medical issues. Upon examination, he is drowsy with a Glasgow coma score of 10 out of 15 and a blood pressure of 165/92 mmHg. He has a right-sided facial droop and no movement in his right arm or leg. He is a smoker and takes amlodipine for hypertension. An urgent CT head scan reveals loss of differentiation between the grey and white matter in the left frontal and parietal lobes, but no acute haemorrhage. What is the most appropriate initial management?
MRCP2-3428
A 63-year-old woman presents with a sudden blurring of vision and pain in her left eye. She recalls experiencing reduced sensation in her left leg 6 years ago, which eventually resolved on its own. On examination, her left eye has significantly worse vision and colour discrimination, and she experiences pain with eye movement in all directions. There are no abnormalities found in her neurological examination of the limbs.
What factor is associated with a poor prognosis in the likely diagnosis of this patient?
MRCP2-3444
A 65-year-old man returns to neurology clinic for review with his wife. He was diagnosed with Parkinson’s disease three years ago and was started on ropinirole nine months ago as his symptoms were becoming difficult to manage. He was mainly concerned with the rigidity of his movements. Since then he has improved remarkably, and his movements are much better, with reduced rigidity on examination. His mood has also been improving with the relief from his symptoms.
However, his wife has become concerned that he has been increasingly spending large amounts on shopping, something which he has not done before and that she feels is out of character. What is the most likely explanation?