MRCP Part 2 Category: Neurology

MRCP2-3378

A 60-year-old woman presented to the neurology clinic with a complaint of progressive weakness over the past 3 months. She initially noticed difficulty opening jars, but over the past month, she also experienced difficulty walking up stairs. She denied any pain or changes in sensation. Her medical history included osteoporosis, type 2 diabetes mellitus, and hypertension.

During the neurological examination, there were no fasciculations, and the sensation was intact. However, power was reduced in finger flexion (3/5), wrist flexion (4/5), knee extension (3/5), and hip flexion (4/5) bilaterally. Upper limb reflexes were present but diminished, and the knee jerk was absent. The plantar response was flexor bilaterally. There was no tenderness over any muscle groups. Cranial nerve examination was unremarkable.

The following blood results were obtained:

– Haemoglobin: 122 g/l
– White cell count: 8.2 x 10^9/l
– Platelets: 376 x 10^9/l
– C reactive protein: 7 mg/l
– Erythrocyte sedimentation rate: 39 mm/hr
– Creatine kinase: 272 (24-170 U/l)

What is the most likely diagnosis?

MRCP2-3379

A 35-year-old female presents to the neurology outpatient department with complaints of severe right-sided throbbing headaches localized to the temporal region. The headaches occur abruptly and last for about 15 minutes, happening 9-12 times a day. She also experiences nasal congestion and rhinorrhoea. She has a family history of migraine and smokes ten cigarettes per day. She does not drink alcohol and has no significant past medical history. On examination, there are no neurological abnormalities. Laboratory investigations and MRI brain are normal. Which medication is the most appropriate treatment for her symptoms?

MRCP2-3380

A 20-year-old male patient visits the clinic with a complaint of motor and verbal tics that are causing him embarrassment. He was diagnosed with Tourette syndrome at the age of 16 and had undergone habit reversal therapy (HRT) which provided partial relief. However, his symptoms have worsened now. He has no significant medical history and is not on any regular medication.

What medication would you prescribe to block the effects of dopamine in the basal ganglia for this patient?

MRCP2-3349

A 32-year-old woman presents to the neurology clinic with a history of lethargy, heat intolerance, pins/needles, and limb numbness for the past 6 months. She has also been experiencing shooting pains in her right hand for the past 4 weeks. Despite multiple visits to her GP and normal thyroid function tests and vitamin B12 levels, her symptoms persist. On neurological examination, there are no consistent findings. An MRI is ordered. What is the most probable diagnosis?

MRCP2-3350

A 50-year-old woman presents to the neurology outpatient department with a 3 month history of headaches. The headaches are localized to her left temporal region. They are sharp and stabbing in nature and occur approximately 10 times a day, lasting for 15 minutes on each occasion. She notices a runny nose and tearing of her eyes when they occur. This has occurred daily for the time period with no period of remission. She has no past medical history and is not on any regular medications.

What is the probable diagnosis?

MRCP2-3351

A 68-year-old man arrived at the Emergency Department complaining of dizziness and vomiting. He had been experiencing symptoms for the past 48 hours and noticed a tendency to sway towards his right side while walking. He had a history of hypertension and was taking atenolol 100 mg/day.
Upon examination, his blood pressure was 160/100 mmHg, with a pulse of 78 bpm. He was alert and oriented to place and time. Fundi were unremarkable. There was impaired conjugate lateral gaze to the right side, and a right-sided gaze-evoked nystagmus was evident. The right orbicularis oculi and oris were mildly weak. The right upper and lower limbs were hypotonic and ataxic. Plantar were flexors on both sides. Pinprick sensation was impaired over the left-sided trunk and limbs.
Which vascular territory is most likely affected?

MRCP2-3352

A 65-year-old man presents with a six-week history of lower back pain that worsens with coughing. He has noticed an increase in his painkiller intake, especially at night, and experiences more pain when straining to pass stool. He has also lost three kg over the last five months. His medical history includes COPD, hypertension, type two diabetes mellitus, and hypercholesterolemia. He has been hospitalized three times in the past year for COPD exacerbations requiring oral prednisolone. He takes Symbicort, tiotropium, atorvastatin, metformin, paracetamol, codeine, and Movicol. He is an ex-smoker with a 50 pack-year history and recently retired early from his job as an accountant due to fatigue. On examination, he appears fatigued and his clothes are loose fitting. There is a 1 cm swelling above his left clavicle, but his chest examination is unremarkable. His abdomen is soft, there is no tenderness over his spine, and a neurological examination is normal.

Observations:
Saturations 95%
Respiratory rate 15/min
Blood pressure 148/87 mmHg
Heart rate 74/min
Temperature 37.4°C

Blood tests:
Hb 128 g/l
MCV 72 fl
Platelets 327 * 109/l
WBC 12.4 * 109/l
Na+ 136 mmol/l
K+ 4.2 mmol/l
Urea 4.1 mmol/l
Creatinine 77 µmol/l

What is the most likely diagnosis to explain his symptoms?

MRCP2-3353

A 67-year-old male presents to the emergency department via ambulance with a sudden onset of bilateral weakness that has been progressing for the past 5 hours. The patient has a medical history of hypertension and hypercholesterolemia and is currently taking amlodipine, ramipril, and atorvastatin. He is a non-smoker.

Upon examination, the patient displays bilateral flaccid weakness in the lower limbs with a power of 0/5 in all muscle groups. The patient is also areflexic and has lost pain and temperature sensation from the level of the umbilicus to the feet. However, proprioception and vibration sense remain intact.

Over the next few weeks, the patient’s weakness becomes spastic in nature, with the lower limbs developing hyperreflexia and upgoing plantar reflexes.

What is the most likely diagnosis?

MRCP2-3354

A 50 year old man presents with a gradual onset of weakness in the extensors of his left wrist and digits over the course of a week. Over the next 2 months, he also experiences weakness in the small muscles of his right hand and is progressively unable to dorsiflex his right foot. On examination, he has 2/5 power and wasting in the left wrist and digit extensors, as well as clawing of the right ring and little fingers with wasting of the small muscles of the hand on that side (excluding the thenar eminence and first two lumbricals). He also has a right foot drop with wasting of the anterior tibial and perineal muscles on that side, and fasciculations are present in all areas of weakness. Sensory examination and reflexes are normal, with no clonus and down-going plantars. Nerve conduction studies reveal conduction block. What is the recommended first-line maintenance treatment for this condition?

MRCP2-3355

A 28-year-old woman is brought to the Emergency Department after being involved in a car accident. During the primary survey, it is discovered that she has a haemothorax on the right side of her body, but her vital signs are stable. She is only responsive to verbal stimuli. A CT scan of her head (with contrast) is conducted:

What is the result of the scan?