MRCP Part 2 Category: Neurology

MRCP2-3404

A 67-year-old man underwent an elective inguinal hernia repair. Due to the list running late into the evening, the patient was admitted for an overnight stay. During the night after the operation the patient was observed to have an increasing oxygen requirement and the following morning was referred to the oncall medical registrar.

The patient reported feeling progressively more short of breath since the operation, particularly when he had tried to lie down to sleep. He denied any cough, chest pain, leg swelling or palpitations. Prior to the operation the patient had been generally well although he had found that he frequently experienced double vision when reading especially in the evening. He also had noticed some difficulties when chewing tough foods in recent weeks. Past medical history was unremarkable and the patient took no regular medications.

Examination revealed a regular pulse, no elevation of jugular venous pressure and normal heart sounds. Both calves were soft and non-tender. The patient had a shallow respiratory effort and was unable to speak in full sentences. Chest expansion was reduced bilaterally, chest was resonant with vesicular breath sounds throughout. The patient had bilateral weakness of facial muscles and ptosis on prolonged upward gaze. Power of neck flexion and extension was reduced, graded as 4/5.

Basic observations:
Blood pressure: 120 / 76 mmHg
Heart rate: 115 beats / min
Respiratory rate: 32 breaths / min
Temperature: 36.8ºC

Portable CXR: technically poor film due to poor inspiratory effort; clear lung fields; no pleural effusion; no upper lobe blood diversion; no free air under diaphragm.

Arterial blood gas analysis (35 % O2)

pH 7.29
PaCO2 6.6 kPa
PaO2 8.7 kPa
Bicarbonate 18 mmol / L (reference 20.0-26.0)
Lactate 2.1 mmol / L

What is the most important next step in managing this patient?

MRCP2-3405

A 65-year-old man presents with a three-week history of double vision and fatigue. He has also been experiencing liquids coming back out of his nose when he swallows. He reports decreased exercise tolerance over the past six months due to fatigue and shortness of breath.

On examination, he appears thin and has bilateral ptosis and diplopia in multiple directions. His voice is soft and he appears peripherally cyanosed. Chest and heart sounds are normal.

Observations:
Heart rate: 90 beats per minute
SaO2: 92% on room air
Respiratory rate: 22 breaths per minute
Temperature: 37.1 degrees Celsius
Blood pressure: 110/68 mmHg

Arterial blood gases breathing air:

PO2 7.80 kPa (11.3 12.6)
PCO2 9.52 kPa (4.7 6.0)
pH 7.31 (7.35 7.45)
bicarbonate 32.4 mmol/L (21 29)
base excess 10 mmol/L (+/- 2)

What urgent investigation should be performed next?

MRCP2-3406

A 65-year-old man presents to the emergency department with worsening anxiety. He has no history of mental health issues, but his wife is concerned that over the past month he has become very nervous and developed panic attacks. Additionally, he is no longer able to carry out his daily tasks. He is retired and usually keeps active, but over the past few weeks, he has become more disengaged and no longer arranges to see friends or leave the house. He has terrors in the night where he screams and takes several hours of calming from his wife.

He is normally well and takes ramipril and a simvastatin for high blood pressure.

On examination, he is withdrawn but alert. He is haemodynamically stable and afebrile. His abbreviated mental test score is 3/10, and he does not know where he is or the time of day. He has mildly increased tone in both arms with occasional myoclonic jerks, and the power is 4/5 in all muscle groups. There is intact coordination and sensation.

Hb 140 g/l
Platelets 398 * 109/l
WBC 7.6 * 109/l

CRP 5 mg/l
Na+ 134 mmol/l
K+ 4.2 mmol/l
Urea 4.3 mmol/l
Creatinine 67 µmol/l

CT head brain atrophy, no intracranial haemorrhage or mass effect
MRI head Hyperintense signals in the left thalamus with some similar changes in both putamen and right thalamus

What treatment should be initiated?

MRCP2-3407

A 25-year-old male presents with a 5-day history of increasing shortness of breath, exertional dyspnoea and bilateral ankle swelling. He has no previous past medical history and was previously a keen sportsman.

On examination, his heart sounds I + II are present with a pansystolic murmur and a displaced apex. Auscultation of his chest demonstrates bibasal crackles. His ECG demonstrates a PR interval of 190 ms but sinus rhythm.

Further neurological examination demonstrates bilateral partial ptosis noted associated with bilateral foot drop. You also note slow release of finger flexion.

What is the underlying diagnosis?

MRCP2-3408

A 55-year-old woman presents to the emergency department with a 3-day history of headache and blurred vision. Despite taking co-codamol and ibuprofen, her headache has not been relieved and she has since started vomiting. She describes feeling generally unwell for the last 2-3 weeks with general malaise and body aches but denies fever and has no past medical history.

On examination, her visual acuity is reduced with noticeable nystagmus more pronounced on the left side. The remainder of her neurological examination is unremarkable.

Laboratory tests:

Hb 99 g/L (115 – 160)
Platelets 150 * 109/L (150 – 400)
WBC 38.3 * 109/L (4.0 – 11.0)
Lymphs 3.2 * 109/L (1.0 – 3.5)
Eosin 0.2 * 109/L (0.0 – 0.4)
Na+ 136 mmol/L (135 – 145)
K+ 3.8 mmol/L (3.5 – 5.0)
Urea 6.2 mmol/L (2.0 – 7.0)
Creatinine 90 µmol/L (55 – 120)
Bilirubin 20 µmol/L (3 – 17)
ALP 87 u/L (30 – 100)
ALT 39 u/L (3 – 40)
Albumin 38 g/L (35 – 50)

What is the most likely diagnosis for this 55-year-old woman with a 3-day history of headache and blurred vision?

MRCP2-3409

A 28-year-old female presents with a 6-month history of continuous left sided facial pain and frontotemporal headache. The pain is described as constantly present and throbbing, with exacerbations of worsened severity every 4 days. She reports exacerbations to typically be associated with injected left eye and left nasal congestion, with occasional teariness in her left eye.

There is no significant past medical history or drug history except for the use of oral contraceptive pills. Routine blood tests are unremarkable, and an MRI head organised by her GP showed no intracranial pathology. However, a trial of indomethacin organised by the physician is positive.

What is the most likely diagnosis?

MRCP2-3410

A 30 year old man presents to the Emergency Department with a sudden and severe headache. What is the underlying cause of his symptoms?

MRCP2-3397

A 48-year-old woman presents to her GP with complaints of fatigue and weakness. She reports feeling completely drained by the end of the day and has difficulty with simple tasks such as combing her hair and walking down stairs. She has also noticed excessive drooping of her eyes and occasional double vision. The patient is a smoker, has rheumatoid arthritis, and recently started taking propranolol for tension headaches. On examination, she exhibits bilateral ptosis, oculoparesis on right lateral gaze, and weakness of neck extension. Blood tests reveal positive muscle-specific kinase antibodies and negative anti-acetylcholine receptor antibodies. A CT scan shows thymic atrophy with no other masses. How would you initially manage this patient?

MRCP2-3398

A 65-year-old man presented to his GP with a six-month history of hoarse voice and choking episodes. In the last few weeks, he had also experienced pulsatile ringing in his left ear with some associated hearing loss. He denied any headache, weight loss, or vomiting and had not noticed any problems with his arms or legs.

The patient had a past medical history of renal stones and hypertension and took allopurinol. He was a smoker of 25 cigarettes per day and did not drink alcohol.

During the examination, the patient had a husky voice with a nasal quality to his speech. There was a left Horner’s syndrome, but pupils were reactive to light and ocular movements were full. Facial movements were normal, and there was no obvious reduction in hearing. On examining the throat, there was sluggish movement of the palate on the left and evidence of left-sided tongue wasting. There also appeared to be some difficulty in shrugging the left shoulder with weakness of chin movement to the right. The remainder of the neurological examination was normal.

Based on the patient’s history and clinical findings, what is the most likely diagnosis?

MRCP2-3383

A 30-year-old woman comes to the clinic complaining of a persistent headache. She has been taking paracetamol, ibuprofen, and codeine daily for the past two months in an attempt to control it, but to no avail. She reports that the headache is present almost every day, but it is not severe enough to incapacitate her. There is a suspicion that she may be suffering from a medication overuse headache.

What is the best course of action for managing this condition?