MRCP Part 2 Category: Neurology

MRCP2-3413

A 68-year-old male presents with a 5-month history of progressive droopiness of his left eyelid. He reports that in the last 3 weeks, he has been unable to lift his eyelid at all, which he says is fortunate considering he gets double vision now when he lifts his eyelid with his fingers. He underwent a renal transplant in 1988, which continues to function well, and previously had a squamous cell and malignant melanoma resected 3 and 6 years ago respectively.

On examination, complete ptosis, loss of vertical eye movements, and loss of adduction are noted in his left eye. On head tilt to the right, he is unable to depress the left eye. His right eye demonstrates full eye movements. The left pupil is unreactive and larger in diameter compared to the right. There is also loss of sensation at the left nasal skin fold and left forehead with sparing of his left chin. He has no facial weakness, hearing loss, or palatal asymmetry. He denies headache or retroorbital pain.

What is the likely location of the lesion?

MRCP2-3414

A 27-year-old woman with a history of left frontal lobe glioma presents to the Neuro-Oncology Clinic six months after post-surgical excision. She reports experiencing several short-lived episodes of right-sided numbness and tingling without loss of consciousness following the operation. A recent MRI brain scan showed no recurrence of malignancy. The patient also has a history of depression. On neurological examination, she demonstrates distal right arm weakness that has not changed since the postoperative phase. She visited the local Emergency Department after a cluster of episodes and was discharged following a period of monitoring. Her investigations revealed normal values for haemoglobin, white cell count, platelets, sodium, potassium, creatinine, albumin, corrected calcium, and magnesium. Her electrocardiogram showed sinus rhythm with a heart rate of 77 beats per minute and a QTc of 427 milliseconds. What is the most appropriate next action in this patient’s management?

MRCP2-3415

A 30-year-old female presents with a 9-month history of progressive lower limb weakness and suprapubic tenderness. During examination, cranial nerves and upper limbs were normal. However, both lower limbs had 1/5 power, hyperreflexic patella and ankle reflexes, bilateral clonus, and upgoing plantar reflexes. Additionally, a suprapubic mass was detected during abdominal examination. After inserting a urethral catheter, a residual volume of 1.8l was noted. The patient has been HIV positive for 10 years. Recent blood tests from an outpatient appointment showed positive results for CMV IgG, EBV IgG, and HTLV antibody, but negative for Hepatitis B and C. An MRI spine is currently pending. What is the most probable diagnosis?

MRCP2-3416

A 49-year-old male presents with a sudden onset occipital headache onset 3 hours ago, associated with slurred speech, vomiting and unsteadiness in all movements. In the 2 hours after admission to the emergency department, it was noted that the patient became increasingly drowsy, deteriorating from a GCS of 15 on admission to E3 V4 M5. On examination, pupils are equal, his speech is dysarthric and bilateral plantars are downgoing. You are unable to elicit more formal power, tone or sensation examination in the patient. An initial CT head is unremarkable but a subsequent MRI head with diffusion weighting sequences demonstrates restricted diffusion in bilateral cerebellar hemispheres with significant swelling around the cerebellum, brainstem and aqueduct. GCS currently 14/15 at 11 hours post-event. You have initiated aspirin 300mg and inserted a nasogastric tube. What is the appropriate management?

MRCP2-3417

A 53-year-old man presents to the emergency department with difficulty moving. He reports a lack of sensation in both lower limbs, causing him to feel unsteady on his feet. His medical history includes type 2 diabetes, hypercholesterolaemia, and hypertension, and he takes metformin, sitagliptin, atorvastatin, and ramipril.

During the examination, the patient exhibits full strength in his upper limbs. However, his lower limbs display increased tone and rigidity, although he can bear weight. While his proprioception is intact, he lacks sensation for pain and temperature.

What is the most probable diagnosis?

MRCP2-3418

A 58-year-old man presents with slurred speech and difficulty eating. His daughter brought him in by ambulance as she noticed his speech was abnormal. The patient denies any changes, but his daughter has observed drooling and inappropriate laughter during conversations over the past few months. On examination, the patient has mild dysarthria and abnormal tongue movement, but his limbs and other cranial nerves are normal. What is the most probable diagnosis?

MRCP2-3419

A 65 year old man has been referred to you by a psychiatrist for a second opinion. He has been experiencing low mood, apathy and suicidal thoughts for the past 3 months. He was also asked to retire early from his job as an accountant due to poor performance. Additionally, he has been sleeping for an average of 14 hours per day.

During his assessment with the psychiatrist, abnormal jerky movements were noted in his lower limbs and he had a broad based gait. His MMSE score was 15/30, which was confirmed during your examination. You also observed hyperreflexia in his lower limbs and nystagmus. He has no history of cognitive impairment or psychiatric conditions, and there is no family history of neurological or psychiatric disorders. His only past medical history is an appendectomy 20 years ago, which was complicated by a large intraperitoneal bleed.

What investigations are most likely to reveal additional information about his condition?

MRCP2-3420

A 25-year-old woman with a history of epilepsy presents to the Emergency department with worsening generalised headache, vomiting, unsteadiness, and blurred vision over the past three days. She has also experienced slurred speech and a one stone weight loss in the past month. On examination, she has dysarthria, bilateral papilloedema, reduced visual acuity, and a broad-based ataxic gait. Investigations reveal bilateral cerebellar haemangiomas. What is the probable diagnosis for this patient?

MRCP2-3421

A 43-year-old woman presents to neurology clinic for evaluation of her treatment plan for multiple sclerosis. She was diagnosed with multiple sclerosis five years ago after experiencing sensory loss and motor weakness in her left leg. Despite having multiple lesions on MRI suggestive of multiple sclerosis, she initially declined disease modifying therapy. However, one year later, she developed optic neuritis and had progression of her radiographic lesions on repeat MRI. She was then started on interferon beta for two years but discontinued due to intolerable side effects. A trial of glatiramer acetate was also unsuccessful due to severe flushing. Since stopping disease-modifying therapy, she has had multiple relapses, including one requiring hospitalization. She meets criteria for aggressive or highly active multiple sclerosis and is interested in later line therapies. She is a science teacher who has been unable to work for the past year due to her relapses.

At this point, the recommended later line therapy is natalizumab. What is the crucial investigation that must be completed before starting treatment with natalizumab?

MRCP2-3422

An 80-year-old man presents with gradually worsening dyspnoea, without any accompanying cough or chest pain. He has a medical history of Parkinson’s disease, rheumatoid arthritis, type 2 diabetes mellitus, and atrial fibrillation. Peak flow tests reveal a decreased Forced Vital Capacity (FVC), an FEV1:FVC ratio of 90%, and a reduced transfer factor for carbon monoxide (TLCO). A high-resolution CT scan confirms the presence of ground-glass changes. Which medication among his current prescriptions is the most likely cause of his lung changes?