A 48-year-old man presented to the neurology clinic with complaints of double vision and flu-like symptoms for the past five days. He reported difficulty closing his right eye fully and noticed a similar problem with his left eye. The patient had recently been diagnosed with type 2 diabetes mellitus and was following a diabetic diet. He had no significant medical history and did not take any regular medication. On examination, the patient had oculoparesis affecting the right lateral rectus and right superior oblique muscle, bilateral facial weakness, and bilateral Bell’s phenomena. He also had arthralgia in his hands and knees. Lumbar puncture revealed elevated CSF protein and white cell count with the presence of oligoclonal bands. MRI brain scan showed punctate periventricular white matter lesions. What is the likely diagnosis?
MRCP2-3384
A 72-year-old patient with a history of Parkinson’s disease presents to the geriatric clinic for evaluation. He has been experiencing sudden attacks where he has difficulty moving for the past few months. Despite being on a stable dose of levodopa and carbidopa for the last three years, his symptoms have been poorly controlled during these attacks. The attacks occur suddenly, last for approximately 30 minutes, and resolve without any intervention. On examination, he has a mild tremor on one side and slight bradykinesia that is more pronounced on the opposite side. There are no postural symptoms when standing, and his eye movements are normal. What is the most likely explanation for his symptoms?
MRCP2-3400
A 25-year-old woman presents to the Neurology Clinic with a 6-month history of diffuse headaches. Initially, the pain occurred only at certain times during the week, but it has now become continuous. She reports that the pain is worse in the morning and she has experienced mild nausea. Her medical history includes depression and acne vulgaris, and she is currently taking fluoxetine, the oral contraceptive pill, and tetracycline.
During the examination, Frisen stage 1 papilloedema affecting both eyes is observed, along with an enlargement of the blind spot and some diplopia on the left lateral gaze. Her body mass index is 32 kg/m2, and there are no other neurological signs.
A magnetic resonance brain scan is performed, which shows no space-occupying lesion. Cerebrospinal fluid (CSF) analysis demonstrates an opening pressure of 33 cmH2O.
What is the next best step in management, given the likely diagnosis?
MRCP2-3385
A 25-year-old man has been referred to the neurology clinic by his GP due to a four-month history of left-sided numbness and intermittent tingling. The symptoms mainly affect his left arm, but he occasionally experiences them in his left leg. He denies any history of headaches, visual problems, or weakness. The GP has conducted several blood tests, including a full blood count, urea and electrolytes, vitamin B12, and C-reactive protein, all of which came back normal. During the neurological examination, the only abnormality found was reduced sensation in the left C6/7 dermatome. An MRI head was performed, and the T2 images are shown below:
What is the most likely diagnosis?
MRCP2-3386
An 80-year-old woman is brought to the Emergency department after being involved in a car accident 3 hours ago. She is currently maintaining her own airway with a respiratory rate of 18 breaths per minute and her SpO2 on air is 97%. Her heart rate is 85 beats per minute and her blood pressure is 140/70 mmHg. Upon examination, she has a visible bruise over the right temporal region and a Glasgow coma score (GCS) of 14. There are no other apparent injuries.
The patient has a medical history of hypertension and atrial fibrillation and is currently taking atenolol and warfarin. She does not remember the accident. While there is a radiology service available on site, the nearest neurosurgical unit is 40 miles away. What would be the most appropriate course of action for management?
MRCP2-3387
A 70-year-old patient was admitted to the hospital after experiencing VF arrest. The ambulance crew reported that CPR was initiated 3 minutes after an out-of-hospital downtime. In the resuscitation room, CPR was successful, and the patient was intubated after the return of spontaneous circulation. Three days later, upon extubation, the ITU consultant observed confusion and bilateral upper limb weakness, which was confirmed to be new with a collateral history. A CT head was performed, followed by an MRI head, which revealed small areas of ischaemic change in bilateral posterior parietal lobes, between middle and posterior cerebral artery territories. CT angiography showed 45% RICA stenosis and 60% L ICA stenosis. The cardiac monitor showed atrial fibrillation, and the echocardiogram revealed septal akinesia, consistent with a recent MI. What is the probable cause of this patient’s stroke?
MRCP2-3388
A 77-year-old man is admitted after being found on the floor at home with no recollection of how he got there or how long he had been there. He complains of feeling generally unwell and having a cough for several days. He has no significant medical history and takes no regular medications. He lives alone and appears disheveled. During examination, bronchial breathing is heard throughout his left mid zone, and he exhibits new onset weakness in left-sided shoulder abduction and adduction, as well as mild weakness in left elbow flexion. Additionally, reduced sensation in the lateral aspect of his upper arm is noted. A CT head is performed.
CT head report shows age-related involutional change with no evidence of intracranial hemorrhage or recent ischemic event.
What is the most likely diagnosis?
MRCP2-3389
A 55 year-old smoker presents with difficulty walking. He used to be able to walk without assistance but now requires the help of his spouse. He reports feeling clumsier than usual. He drinks 2 cans of beer every week. He takes atorvastatin for high cholesterol and has been on aspirin for 8 years since his doctor prescribed it. He has lost a significant amount of weight recently, but is unsure of the exact amount.
During the examination, he appears cachectic. He has an intention tremor and displays dysdiadochokinesia. His gait is broad-based. He has bilateral nystagmus on horizontal gaze. Upon auscultation of his chest, there is some bronchial breathing on the right middle lobe. His vital signs are normal.
CT scan of the head shows no acute intracranial abnormalities.
What is the most appropriate test to perform next?
MRCP2-3390
A 75-year-old male presents with a two-year history of progressive unsteadiness on walking. He had previously been very active, walking around 3 miles every day and only retired as a teacher 4 years ago. He underwent chemotherapy for localised squamous cell carcinoma of his tongue 20 months ago but otherwise had no other past medical history. He admits to having drunk ‘more than he should have’ while in college but says he has since cut down to moderate levels. He stopped smoking 6 years ago, with a 35 pack year history. Over the past 4 months, he has become incontinent of urine and has to rely on pads, which he is greatly embarrassed by.
On examination, he has a shuffling gait in his lower limbs with good arm swing. He is markedly slowed and takes 130 seconds to walk 25 metres. He turns around 180 degrees in 7 steps with no resting tremor, rigidity or bradykinesia. Examination of his tone, power, sensation, coordination and reflexes are all unremarkable. His voice is quiet and whispering. His cranial nerves are normal with a full range of eye movements. An abbreviated mental test scores 8/10, a Montreal cognitive assessment (MOCA) scored 28/30. His initial blood tests are as follows:
An MRI head is performed, demonstrating diffuse mild microangiopathic changes with prominently dilated lateral and third ventricles. No intracranial masses are noted. You perform a lumbar puncture, with the patient lying in the left lateral position using a 22G spinal needle and obtain cerebrospinal fluid with the first pass. His opening pressure is 17.2 cmH2O. What is the most appropriate course of action?
MRCP2-3391
A 38-year-old male presents to your outpatient clinic with a progressive history over the past 5 years of increasing, progressive ‘clumsiness’. His work colleagues had a long running joke with him that he is poorly coordinated for about the past five years but in recent weeks, he has noticed that he is unable to write legibly or even hold a key still using either hand to open a door. He denies any recent weight loss of night sweats, is otherwise healthy with no other past medical history. He is a lifelong non-smoker with a minimal alcohol history and lives with his wife and 2 children.
On examination, his cranial nerves were unremarkable except for mild multidirectional nystagmus at primary gaze. Fundoscopy was normal. Limb examination revealed a significant impairment of finger-nose and heel-shin testing. His gait, tone, power, sensation and reflexes were normal with downgoing plantars. A brief mini-mental state examination scored 30/30. An MRI head is awaited. His blood tests are as below: