MRCP Part 2 Category: Neurology

MRCP2-3392

A 55-year-old Caucasian female from Australia is seen at the walk-in urgent care centre with a persistent left-sided temporal headache and double vision that has been gradually developing over the past four days. Although she has a history of migraines, they are usually well-controlled. She is independent and has no significant family history, and she only takes the oral contraceptive pill. During the examination, you observe a loss of the afferent pupillary reflex on the left side, as well as a loss of vertical gaze and an inability to adduct her left eye. Additionally, she has reduced sensation to light touch on the left forehead and cheek, but it does not cross the midline. What is the most probable diagnosis?

MRCP2-3393

A 45-year-old female presents with a second episode of loss of sensation in her left anterior thigh and right foot. This is her second episode within the past six months. She had recently reported an episode of left anterior shin numbness 2 years ago when an MRI with gadolinium demonstrated ‘spots in her spinal cord’ and she was diagnosed with transverse myelitis. Her past medical history also includes ulcerative colitis, diagnosed aged 28 years old and primary sclerosing cholangitis. Her serum tests are as follows:

Hb 125 g/l
Platelets 274 * 109/l
WBC 7.5 * 109/l

Na+ 139 mmol/l
K+ 4.4 mmol/l
Urea 4.7 mmol/l
Creatinine 78 µmol/l
Bilirubin 49 µmol/l
ALP 305 u/l
ALT 180 u/l

What would be the most appropriate next step in management after commencing five days of high dose oral methylprednisolone?

MRCP2-3394

A 55-year-old male is brought to the emergency department by his worried wife after falling down a flight of 12 stairs at home and hitting his head. Despite his wife’s concerns, the patient does not seem worried and thinks he could have stayed at home. He denies experiencing a headache, nausea, vomiting, seizures, or loss of consciousness between the fall and examination. He is not taking any regular medications, including anticoagulants, and remembers everything except for about 20 seconds after landing at the bottom of the stairs. During the examination, there is no limb weakness or loss of sensation, and his pupils are equal and reactive bilaterally. What is the most appropriate course of action?

MRCP2-3395

A 29-year-old gentleman student from Germany presents to you with right foot drop ongoing for two weeks with some numbness and tingling of the foot. These symptoms developed after he knelt down to pick something up from the floor. Three years ago he woke up from sleep with clawing of his fourth and fifth digit after having been asleep in a prone position and this lasted a week. Eight years ago he also had a left wrist and finger drop lasting three weeks after he sat on the couch with his left arm draped over the back of the couch for ten minutes. He denies falling asleep or remaining on the couch for a prolonged period. He has no other past medical history of note and has never sought medical advice for his problems.

On examination, there is right foot drop (2/5 power) and similar weakness of dorsiflexion and eversion of the right foot. There is also sensory loss over the lower lateral part of the right leg and dorsum of the right foot in all modalities. Reflexes are intact. Neurological examination and general examination are otherwise unremarkable. Which of the following tests would confirm the suspected diagnosis?

MRCP2-3396

A 72-year-old right-handed male presents with sudden onset flaccid left upper and lower paralysis with complete dysphasia. His son reports him to have been well two hours ago.

On examination, the patient scores 0/5 on his left upper and lower limb, at least 4/5 on both right limbs (examination was difficult due to his dysphasia), with a loud carotid bruit. He is also now in atrial fibrillation, a new diagnosis for him. He is well known to the stroke team: 8 weeks ago, he was admitted with a left middle cerebral artery ischaemic stroke, leaving him with minimal residual weakness on his discharge.

During his admission, he was found to have 80% carotid stenosis in his left internal carotid artery and 70% in his right internal carotid artery, for which he declined surgery. His other past medical history includes hypertension, type 2 diabetes mellitus and dyslipidaemia. He does not take any anticoagulants. A CT head demonstrates a hypodensity in the right middle cerebral artery area distribution, consistent with an acute ischaemic stroke with no areas of haemorrhagic transformation.

What is the most appropriate next course of action?

MRCP2-3365

A 55-year-old man comes to the clinic with complaints of difficulty walking and disorientation. He also reports experiencing blurred and double vision. Upon examination, he displays severe vertical and horizontal nystagmus and depression of the deep tendon reflexes. The patient rarely visits his GP and is not taking any medication. He is a heavy smoker, consuming 60 cigarettes a day, and drinks a bottle of cider daily. What vitamin deficiency is associated with this condition and requires replacement?

MRCP2-3381

A 65-year-old retired teacher was admitted to a Neurology Ward 3 weeks ago following a series of seizures. Her family report that she was last completely well 6 months ago.
At that time, a change in her behavior was noted with frequent forgetfulness, confusion, and difficulty with simple tasks. Over the next few weeks, she was reported to be increasingly irritable and agitated. In the following weeks, her family have noticed that she has been increasingly unsteady on her feet, often stumbling and having difficulty with balance. The neurology team are concerned about continued cognitive deterioration, despite treatment for a recent suspected infection, and have referred her for medical advice. Over the last week, jerking movements have also been noted in her arms.
On examination she is confused, bed-bound and catheterised with spontaneous and stimulus-sensitive myoclonus. Mini-Mental State Examination reveals a score of 10 out of 30, with global deficits. A bilateral grasp reflex together with pout and snout reflexes are present. Tone is increased in all of the limbs, with symmetrically brisk reflexes and bilateral extensor plantars. Although she has difficulty following commands, there is demonstrable ataxia and apraxia of the upper limbs.
Which one of the following investigations is most specific in securing the diagnosis in this case?

MRCP2-3366

A 28-year-old man presents to ambulatory care with a sudden onset of facial droop. He works as a rock climbing instructor and is concerned that this may be related to a fall he had while climbing a few weeks ago. He has been experiencing general malaise, body aches, and unexplained bruising on his leg, which has prevented him from climbing for the past few weeks.

Upon examination, he has bilateral weakness of the VII nerve, but no other cranial nerve deficits are detected. There are no focal neurological abnormalities in his arms or legs. His skin is intact, and there are no visible skin lesions. All joints appear to have a full range of motion, and there is no evidence of joint effusions.

Laboratory investigations reveal a hemoglobin level of 127 g/L (normal range: 130-180) and a white cell count of 10.0 × 109/L (normal range: 4.0-11.0). A chest X-ray is normal.

What is the most likely diagnosis?

MRCP2-3382

A 35-year-old woman presents with a complaint of reduced sensation. She reports that over the course of six months, she has not been able to feel when hot water splashes on her hands, despite developing blisters afterwards. Her husband has urged her to seek medical attention. She denies any other issues, including weakness, weight loss, or difficulty with daily activities. She has a history of asthma but only uses her salbutamol inhaler infrequently. She has no known allergies or other medications. Upon examination, she exhibits sensory loss in the dermatomes C4 to C6, with a symmetrical distribution affecting her hands and arms when tested for temperature and pain. There is no tenderness upon spinal examination, and her cranial nerve and lower limb examinations are normal. What is the most likely diagnosis?

MRCP2-3367

A 55-year-old accountant presents with a constant headache for the past two weeks and has had two seizures in the last 24 hours. His family reports a change in his character, increased aggression, weakness, decreased appetite, and a weight loss of 2 lbs over the past week.

The patient has a history of HIV and underwent an anterior resection for rectal carcinoma three years ago. A recent endoscopy revealed gastric polyps. He is currently taking oral antibiotics for sinusitis.

On examination, the patient has reduced power in the left upper limb and reflexes are reduced on the left side. Power is mildly reduced in the left lower limb with an upgoing plantar and normal sensation. The patient has a Glasgow Coma Score of 13 and is drowsy. Pupils are equal and reactive, but there is papilloedema. His observations show a heart rate of 96 beats per minute, blood pressure of 110/98 mmHg, temperature of 38.0’C, and respiratory rate of 18 per minute with saturations of 98%.

Lab results show a normal electrolyte balance and creatinine levels, but the patient has a low hemoglobin count and elevated white blood cell count. Blood cultures are pending, and a CT head has been requested.

What is the likely diagnosis?