MRCP Part 2 Category: Neurology

MRCP2-3320

A 22-year-old woman is suffering from treatment-resistant depression. Despite being under the care of psychiatrists for two years and trying various anti-depressants, her symptoms remain uncontrolled. She was recently started on moclobemide four days ago.

During examination, she appears acutely unwell, confused, and tremulous. Her temperature is 39°C and her blood pressure is 155/100 mmHg. Although her chest, heart, and abdomen appear normal, she has rigidity with greatly increased tone in all limbs and ankle clonus. A septic screen came back negative.

What is the most likely diagnosis?

MRCP2-3321

A 50 year old male presents with right shoulder pain and weakness. He had been brought to the emergency department (ER) three weeks ago with the same complaint. The pain was severe and woke him up from sleep. He took two paracetamol tablets but they provided no relief. Eventually, the ER team had to administer morphine to alleviate his agony after trying less potent analgesia. He described the pain as sharp, worsened by shoulder movement, and accompanied by numbness at the shoulder tip.

During examination, he held his right arm with his left one in adduction and internal rotation. Deltoid muscle wasting was observed, and the biceps tendon jerk was absent. Sensations were intact except in a small area over the deltoid muscle. His lower limb examination was normal. He had a history of flu one month ago and admitted to drinking alcohol at least four times a week. He has a ten-year-old son who is an insulin-dependent diabetic.

The following investigations were conducted:

Hb 14 g/dl
Platelets 180 * 10^9/l
WBC 6 * 10^9/l
MCV 85 fl
MCH 0.6 fmol/cell
MCHC 21 mmol/l
Na+ 135 mmol/l
K+ 4 mmol/l
Creatinine 85 µmol/l
Urea 3.2 mmol/l
ESR 4 mm/hr
ANA negative

What is the most probable diagnosis?

MRCP2-3322

A 35-year-old man from the Caribbean presented with a gradual decline in his ability to move over the past six years. He had been living in the UK for the last 4 years, having previously resided in India. Initially, he complained of back pain and then began to experience difficulty lifting his feet while walking, which resulted in several falls. Over the last 3 years, he had a frequent urge to urinate and had experienced incontinence on two occasions. He had also been constipated during this time. He reported that his brother, who also lived in the UK, had been experiencing similar symptoms.

During the examination, his cranial nerves and upper limbs were normal. However, there was increased tone bilaterally in his lower limbs, pyramidal distribution weakness in both limbs, and increased reflexes throughout with upgoing plantar reflexes. Coordination was normal, but there was a sensory level at T10. Additionally, generalised lymphadenopathy was observed.

What is the most likely diagnosis?

MRCP2-3323

A 72-year-old male with metastatic breast cancer presents with back pain. Upon further questioning, he reports experiencing pins and needles in his legs. The nursing staff reports that he has developed urinary incontinence over the past 12 hours.

What is the appropriate management for this patient?

MRCP2-3324

A 73-year-old man presents to the oncology team with progressive lower thoracic back pain over the past three weeks. The pain has now reached an intensity that has prevented him from sleeping during the past two nights, despite over the counter analgesics. What investigations are appropriate for his back pain?

MRCP2-3325

A 30-year-old woman visits her GP with complaints of difficulty climbing stairs at home. She mentions that her mother passed away in her early 50s due to severe pneumonia, and had trouble breathing and had to sleep propped up for several months before her death. The patient reveals that her parents were first cousins. She also reports struggling with exercise and sports during her school years and currently has a sedentary job in an office.
During the examination, the GP observes proximal weakness in her legs with lower motor neurone signs. There is mild upper limb weakness, but it is not as severe as in the lower limbs.
What is the most probable diagnosis?

MRCP2-3326

A 57-year-old woman presented to the hospital with symptoms of sweating, nausea, palpitations, and intermittent crawling sensations in her hands and feet spreading up her arms and legs. She had recently visited her GP due to severe nausea and vomiting, and as a result, her GP had stopped all her medications. The patient had a medical history of hyperthyroidism, anxiety, depression, and atrial fibrillation, for which she was taking carbimazole, propranolol, paroxetine, amiodarone, and aspirin. Within two days of stopping her medications, she developed the aforementioned symptoms, along with anxiety, erratic behavior, and vivid dreams. On examination, her blood pressure was 140/78 mmHg, pulse was 97/min and irregularly irregular, and neurological examination revealed poor attention and concentration. Investigations showed abnormal levels of haemoglobin, white cell count, and serum potassium. Based on this information, which medication withdrawal is likely responsible for the patient’s symptoms?

MRCP2-3327

A 48-year-old woman presented to the general medical clinic with a complaint of progressive diffuse myalgia and weakness that had been ongoing for three months. She reported experiencing difficulty walking up and down stairs due to weakness in her shoulder muscles and thighs. Her medical history included hypertension and hyperlipidemia, for which she took atenolol and simvastatin regularly. On examination, there were no abnormalities in the cranial nerves or detectable neck weakness. However, there was general myalgia in the upper limbs and proximal weakness of 3/5 with preserved distal power. A similar pattern of weakness was observed in the lower limbs with preserved tone, reflexes, and sensation.

The following investigations were conducted: haemoglobin, white cell count, platelets, ESR (Westergren), serum sodium, serum potassium, serum urea, serum creatinine, plasma lactate, serum creatine kinase, fasting plasma glucose, serum cholesterol, plasma TSH, plasma T4, and plasma T3. Urinalysis was normal.

Based on these findings, what is the likely diagnosis?

MRCP2-3328

A 25 year-old individual with epilepsy is admitted to the hospital with generalised tonic-clonic status epilepticus. The patient is currently on phenytoin. Despite receiving intravenous diazepam and phenobarbital, the seizures continue after 30 minutes.

What would be the most appropriate next step in managing this patient’s condition?

MRCP2-3329

A 35-year-old Nigerian woman was referred for evaluation of progressive weakness and tingling in her lower limbs over the past 5 months. She has also noticed a decline in her vision and difficulty hearing the television. She is currently unemployed and struggling financially.

During examination, she had excoriations around the mucocutaneous junction of her mouth. Fundus examination revealed pale optic discs on both sides. Rinne’s test showed air conduction to be better than bone conduction. Audiogram revealed that she could hear 8000 Hz at 60 decibels and 250 Hz at 20 decibels.

The distal groups of muscles in all limbs were weak with 4/5 power, and tendon reflexes were reduced. Romberg’s test was positive.

What is the most likely diagnosis?