MRCP Part 2 Category: Neurology

MRCP2-3423

A 28-year-old male presents with sudden left-sided weakness, expressive dysphasia, and dress apraxia. He has a history of progressive cognitive impairment and seizures for the past six years. He lives in a sheltered accommodation and was brought in by his relatives who noticed a change from his baseline. The patient has difficulty recalling the duration of his symptoms. He reports a recent burning sensation while urinating, increased frequency, and reduced oral intake for the past five days. An MRI of the head shows multiple areas of ischemia in the left and right cortex, inconsistent with a single vascular territory. A urine dip test is positive for leukocytes and nitrites but negative for ketones. A venous blood gas test reveals:

pH 7.15
PaCO2 2.4 kPa
Bicarbonate 6 mmol/l
Lactate 18 mmol/l
Anion gap 16 mmol/l

What is the underlying diagnosis that explains all of these symptoms?

MRCP2-3424

A 50-year-old Bangladeshi male presents with a 6-month history of bilateral reduced sensation on the tips of both his feet, which has gradually progressed on both legs to his low shins. His past medical history includes type 2 diabetes, diagnosed 10 years ago and reports good medication compliance with metformin 500mg BD alone, with a HbA1c of 48 mmol/mol (6.5%) two weeks ago. He is also currently in his ninth month of anti-tuberculosis treatment, having initially presented with a chronic cough, night sweats and weight loss. An induced sputum subsequently cultured positive for acid-fast bacilli. He did not bring in his medications but remembers being told they are ‘the standard four then two drugs’. He takes no other medications and has no known drug allergies. On examination, tone, power and gait of his lower limbs are unremarkable. He demonstrates reduced sensation to light touch to his left lower shin and right mid-shin. Ankle jerks are absent bilaterally, plantars are downgoing bilaterally. What is the most likely diagnosis?

MRCP2-3425

A 70-year-old male has been diagnosed with dementia after experiencing a gradual decline in cognitive function over the course of a year. Specifically, he has shown deficits in planning, attention, cognitive flexibility, visual memory, and visuospatial manipulation on detailed neuropsychological assessments. His mini-mental state examination score is 15 out of 30. The patient has a history of Parkinson’s disease and has been taking Madopar for the past 6 years. During a clinic visit, the patient’s son expresses a strong desire to start treatment. What is the most readily available treatment option?

MRCP2-3426

A 79-year-old male visits a Parkinson’s disease clinic complaining of frequent episodes of complete immobility lasting up to 20 minutes, occurring up to four times daily. He has been diagnosed with Parkinson’s disease for the past six years and is currently taking Sinemet 125 as his only medication. What is the most suitable treatment to alleviate his motor fluctuations?

MRCP2-3411

A 35-year-old man presents with increasing muscle weakness. He visited his primary care physician (PCP) 5 days ago, reporting difficulty standing up from a seated position. His family has brought him to the Emergency Department as he is having trouble swallowing and can only produce garbled speech.
During the examination, there is a noticeable overall weakness with absent reflexes on both sides. Upon further inquiry, he mentions having experienced food poisoning approximately four weeks ago. Electrophysiological tests reveal indications of conduction block at various locations.
What is the most probable diagnosis?

MRCP2-3427

A 23-year-old male presents to the clinic after being referred by his GP. He has been noticing that his eyelids appear to be drooping more and more over the past 10 months, which has been commented on by his friends. He denies experiencing any muscle weakness or double vision. He has no significant medical history and does not smoke or drink alcohol. Upon examination, bilateral abduction and adduction of his eyes are impaired, and there is inconsistent impairment of vertical gaze. His neurological examination of the upper and lower limbs is unremarkable, except for mild finger-nose dysmetria. Blood tests show no abnormalities, and his ECG shows sinus rhythm with a PR interval of 260 ms. Fundoscopy reveals a pigmented retina. What is the likely diagnosis?

MRCP2-3412

A 49-year-old woman experiences a sudden-onset headache on the left side of her face and neck while at rest 24 hours ago. The pain is severe, rated at 10/10, and started suddenly. It has not subsided and is throbbing in nature. She also had a brief episode of vision loss in her left eye that lasted for two hours before resolving. Since then, she has noticed that food tastes strange. On examination, she has a small, sluggishly light-responsive left pupil compared to the right and partial left ptosis. The rest of her neurological examination is unremarkable. Routine blood tests are normal, and a plain CT scan of the head is unremarkable. A lumbar puncture does not show xanthochromia. A CT angiogram of the head and neck vessels reveals a pseudo-lumen of the carotid artery. What treatment would you initiate?

MRCP2-3401

A 65-year-old male arrives at the emergency department via blue light ambulance 90 minutes after experiencing sudden onset right-sided weakness and expressive and receptive dysphasia. He has a medical history of T2DM, hypertension on 3 agents, and a 40 pack year smoking history. Upon examination, he exhibits a dense 0 out of 5 right hemiparesis and complete expressive and receptive dysphasia, confirmed by collateral history from his wife. The patient scores an NIHSS score of 7 and has no recent surgery or head trauma, nor is he on an anticoagulant or has a history of coagulation disorders. A CT head reveals no areas of hemorrhage but a likely evolving area of ischemia in the left middle cerebral artery territory, with an ASPECT score of 8. Upon arrival, his vital signs are as follows: temperature 36.7 degrees, heart rate 90/min and regular, blood pressure 220/150 mmHg, sats 99% on air, respiratory rate 20/min. What is the most appropriate first-line treatment?

MRCP2-3402

An 82-year-old man presents to the emergency department after a mechanical fall. He has sustained a head injury and a CT head is ordered as part of his trauma evaluation. His medical history includes osteoarthritis of the left hip, recurrent falls, and atrial fibrillation for which he is anticoagulated.

Upon examination, his respiratory rate is 18/min and he is saturating at 95% on air. His heart rate is 78/min and his blood pressure is 92/65 mmHg. Neurological examination reveals a Glasgow coma score of 13 due to confusion, but there are no focal neurological deficits. He has no spinal, limb, chest, or abdominal tenderness, and a full painless range of motion in all four limbs.

The CT head image is shown below:

What is the diagnosis in this case?

MRCP2-3403

A 50-year-old man is admitted to the stroke unit with a right total anterior circulation syndrome (TACS) infarct. He arrived at hospital 2.5 hours after the onset of his symptoms and was treated with intravenous alteplase at 3 hours post-onset.

He is known have an atrial septal defect which was discovered after a murmur was heard at a routine insurance medical several years ago. He works in the oil business and has recently returned from a business trip to Saudi Arabia.

On examination the following day there subtle signs of improvement with increased movement in his left hand. However, the rest of his arm remains flaccid and he has persisting dense hemiplegia affecting his right leg. He has a notable homonymous hemianopia on examination. A routine CT Brain 24-hours post-thrombolysis revealed established ischaemic changes in the MCA territory with new petechial haemorrhage along the border of the infarct.

Later that evening, his conscious level falls. His Glasgow Coma Scale changes from E4 M6 V2, to E2, M4 V2. His blood pressure is 187/112 mmHg.

Urgent bloods reveal:

Haemoglobin 120 g/l
Prothrombin time 27 seconds
Activated partial thromboplastin time (APTT) 49 seconds

What is the most beneficial intervention for this patient?