A 72-year-old man presents to the Emergency Department after experiencing a sudden collapse. Prior to the collapse, he had been complaining of a severe headache at the back of his head. The patient has a medical history of hypertension, which is being managed with two oral medications.
Upon examination, the patient’s mean arterial pressure is 140 and his pulse is regular at 88 beats per minute. Bilateral papilloedema is observed, and the patient’s Glasgow Coma Scale score is reduced to 13. Despite confusion, the patient is able to move all four limbs. A CT scan of the head reveals evidence of a large subarachnoid haemorrhage.
What is the target for cerebral perfusion pressure in this patient?
MRCP2-3342
A 25-year-old woman presents with a fever and headache that started suddenly and has worsened over the past 24 hours. She is experiencing difficulty looking at lights and neck stiffness. Upon examination, she is febrile and photophobic, but has no focal neurological deficits or rash. A lumbar puncture is performed and the results show elevated lymphocytes and protein levels, as well as a positive viral PCR for Herpes simplex virus type 2. She is currently receiving IV ceftriaxone and dexamethasone for presumed bacterial meningitis. What is the most appropriate course of action?
MRCP2-3343
A 55-year-old Asian woman with a medical history of hypertension, ischemic heart disease, type 2 diabetes mellitus, and colon cancer resected two years ago, presents to the Emergency department with a one-week history of cough and shortness of breath. She has been experiencing chronic mild right ear ache with some discharge and mild right-sided headache, but no reported neck stiffness or photophobia. Occasionally, she has been choking when drinking and her voice has become hoarse.
During examination, the patient was afebrile and had normal vital signs. There were scarce crepitations on the right base of lung. Cranial nerve examination revealed deviation of uvula to the left and her left palatolingual fold was positioned higher than the right. On protrusion, the tip of the tongue was deviated to the right. Limb examination was normal with negative Babinski’s sign bilaterally.
Blood results showed normal levels of sodium, potassium, creatinine, urea, albumin, total bilirubin, alkaline phosphatase, and ALT. However, the patient had an elevated ESR and CRP. Her hemoglobin, WBC, and platelet counts were within normal ranges, but her neutrophil count was slightly elevated.
What is the most likely diagnosis for this patient?
MRCP2-3344
A 32-year-old woman presents to the General Neurology Clinic with a history of progressive gait deterioration over the past 14 years, requiring the use of a frame for assistance. She also reports a gradual decline in her hearing over the last 3 years. Upon further inquiry, it is discovered that her maternal grandmother had a history of seizures, her mother experienced hearing loss in her 50s, and her mother’s sister was diagnosed with multiple sclerosis. What is the most probable diagnosis in this case?
MRCP2-3345
A 20-year-old woman presents to her clinic appointment in distress. She has been experiencing severe headaches for the past year, causing her to drop out of her university studies. The headaches are debilitating and often prevent her from doing anything else. She experiences vomiting most days of the week when the pain is at its worst, and her vision feels blurry. Despite trying sumatriptan, NSAIDs, paracetamol, and relaxation techniques, her GP has been unable to provide much relief. She is currently taking sertraline for depression and does not smoke.
The patient’s headaches are a constant, severe frontal headache with radiation around the eyes. She can vomit at times, often before breakfast. She has rarely found relief from her symptoms, but notes that they are better in the evenings.
On examination, the patient has normal visual fields, equal limb strength, and normal tone. There is no sensory loss. Her fundi show no bleeds or exudate, but the disc is blurred. She has a raised body mass index of 26kg/m² and is afebrile. There is no sinus tenderness, and no inflammation of the upper respiratory tract mucosa can be seen.
Her blood work shows: – Na+ 138 mmol/l – K+ 4.3 mmol/l – Urea 5.1 mmol/l – Creatinine 87 µmol/l
A CT scan of her head shows no intracranial haemorrhage, mass effect, or lesions seen. However, an MRI scan shows flattening of the sclera of the eye, partially empty sella turcica, and an enlarged subarachnoid space around the oculomotor and optic nerves.
What is the likely diagnosis?
MRCP2-3331
A 26-year-old F1 driver presents with neck pain after a race. After three days, he complains of numbness on the left side of his face and right upper and lower limbs. During examination, it is found that he has lost pain and temperature sensation on the left side of his face and right upper and lower limbs. Additionally, his left pupil is smaller than the right and he has partial ptosis on the left. Eye movements are normal, and power, coordination, and reflexes are all normal. What is the preferred brain imaging method used to establish the primary diagnosis?
MRCP2-3332
A 65-year-old woman presents with a 4-month history of fatigue and unsteadiness. She has a medical history of type 2 diabetes mellitus for the past 5 years and hypothyroidism for the past year. She is currently taking metformin 500 mg tds and thyroxine 100 µg daily, and her most recent thyroid function tests were normal. On examination, she has spastic paraparesis, absent knee and ankle reflexes, extensor plantar responses, absent joint position sense up to knees with normal pain sensation. What is the most likely diagnosis?
MRCP2-3317
A 60-year-old overweight man (body mass index 36) is experiencing recurrent transient ischaemic attacks despite being on aspirin 75 mg. He had a minor stroke three years ago which resulted in permanent balance loss. His blood pressure is well controlled with ramipril at 140/80 mmHg, and his fasting blood glucose is 4.8 mmol/l. A 48-hour ECG Holter monitor showed he remained in sinus rhythm. According to the NICE clinical guidelines for stroke, what is the most appropriate treatment for this patient?
MRCP2-3318
A 23 year old woman is brought to the Emergency Department by ambulance. She is accompanied by her sister who tells you she thinks she has taken a deliberate overdose of up to 70 fluoxetine tablets (20mg) within the past six hours. On assessment her airway is patent but threatened with a respiratory rate of 28 and peripheral oxygen saturations of 96% on air. Her chest is clear. The heart rate is 122 bpm and the blood pressure is 100/40 mmHg. Capillary blood glucose is 4.8 mmol/L. The ECG shows a sinus tachycardia with QRS duration 118 msec and corrected QT interval 580 sec. She is globally hypertonic, shivering, nauseated, vomiting and sweaty with a tympanic temperature of 37.5°C and dilated pupils and prominent clonus. She suddenly has a prolonged tonic-clonic seizure and receives 15 mg intravenous diazepam with no response after 20 minutes.
What is the safest course of action for managing this patient?
MRCP2-3319
An 80-year-old man presents with tremor and mobility issues. Upon examination, he displays a resting tremor that is more pronounced in the right hand, along with bradykinesia and mild rigidity. His cognitive function and speech are unaffected, and his blood pressure is 130/85 mmHg with no significant postural drop. Given his symptoms, idiopathic Parkinson’s disease is suspected. However, further history reveals that the patient had a significant gambling problem in the past, which is now well-controlled.
Which medication should be avoided in this patient?