MRCP Part 2 Category: Neurology

MRCP2-3287

A 55-year-old man presents to the outpatient clinic with a six week history of progressive gait difficulties and dysarthria. He has had several falls recently and his friends have noticed he walks as if drunk. He does not complain of headache or visual disturbances, and has not noticed any problems with breathing, bowel or bladder function. His past medical history is unremarkable. He is a non-smoker and drinks seven units of alcohol per week. There is no relevant family history.

On examination, he is alert and orientated, with marked dysarthria. There are no rashes or palpable masses. On examination of the cranial nerves, he has bilateral gaze-evoked horizontal nystagmus, fundoscopy is normal as was the rest of the examination. On peripheral nerve examination, he has a marked bilateral intention tremor in both upper limbs. Tone, power, reflexes and sensation all appear normal. He walks with a broad based gait and is unable to heel-toe walk. Chest, cardiovascular and abdominal examinations are all normal.

An MRI brain scan with gadolinium contrast was normal. The data from a lumbar puncture showed:

– Opening pressure 12 cmH2O
– CSF protein 0.94 g/L
– CSF white cell count 20 cell per ml (90% monocytes) (≤5)
– CSF red cell count 2 cells per ml (≤5)

A chest x-ray was normal. Which investigation listed below is likely to lead to a diagnosis?

MRCP2-3288

A 60-year-old male with a 50 pack year smoking history has been diagnosed with small cell lung cancer. He is currently undergoing chemotherapy. Over the past several months, he has been experiencing a decline in his vision and complains of double vision. He also feels weaker in his upper limbs, although his symptoms do vary.

During the examination, he displays mild ptosis of the eyelids on both sides and a complicated ophthalmoparesis that affects both eyes. Additionally, he has decreased power proximally in his upper limbs.

In this clinical syndrome, which of the following blood test results is likely to aid in the diagnosis, in addition to electrophysiological studies?

MRCP2-3289

A 67-year-old man presented with a one-year history of difficulty walking and turning around. He also complained of stiffness in his right arm and worsening handwriting. His wife noticed his right arm moving uncontrollably at times and he had difficulty with speech, occasionally mispronouncing words. On examination, he had increased tone in his right arm and leg with difficulty in fine finger movements. What is the most probable diagnosis?

MRCP2-3290

A 50-year-old man presents to the neurology clinic with a six-month history of tremor affecting both hands, which worsens with emotional stress. He has no medical history and does not take any medications, smoke, or drink alcohol. He works as a carpenter.

During the examination, a 5 Hz frequency and medium amplitude tremor is observed in both hands, which is slightly more prominent on the right hand. The tremor is present both posturally and at rest, with no other distinguishing characteristics.

What is the most appropriate test to guide diagnosis based on this clinical presentation?

MRCP2-3291

A 58 year-old consultant surgeon has recently been diagnosed with idiopathic Parkinson’s disease and is attending clinic for review. The previous clinic letter shows that he presented with a tremor affecting mainly the right hand, which forced him to stop operating. On examination, he also had some bradykinesia and rigidity of the right hand. He was started on co-beneldopa 100/25, initially one tablet three times daily, with instructions to up-titrate as tolerated.

During today’s visit, the surgeon expresses concern that there has been no improvement in the tremor. This is causing him considerable distress as he hopes to return to clinical work. Although his motor control is otherwise good, and he has no difficulty with ‘off’ periods or freezing throughout the day and night, he currently takes co-beneldopa 100/25, two tablets three times daily, and reports no complications.

On examination, there is a resting tremor of the right hand, but no discernable rigidity or bradykinesia. What is the best treatment option?

MRCP2-3292

A 68-year-old male arrives at the hospital with sudden onset of right-sided weakness and speech impairment that has lasted for two hours. A CT cerebral angiogram reveals thrombosis in the proximal left middle cerebral artery (LMCA). The patient had undergone laparotomy for bowel obstruction caused by an incarcerated umbilical hernia seven days prior to this incident. In the absence of IV thrombolysis, what emergency treatments could potentially help this patient?

MRCP2-3293

A 38-year-old male presented with a 6-month history of weakness affecting his upper limbs. He found that this was worse at the end of the day, particularly if he had been doing a lot of lifting. He also reported occasional difficulty in swallowing at the end of the day, with drinks causing him to cough. He had been prescribed pyridostigmine, but he stopped taking this as he had not noticed any benefit.

On examination, there was a mild partial ptosis, and a slight facial droop bilaterally. Extra-ocular movements were normal. Power in shoulder abduction was grade 4/5 bilaterally, but was reduced to 3/5 after repeatedly abducting and adducting the shoulder 20 times. Tone and sensation were normal.

Initial investigation results are shown below:

Nerve conduction studies: Decremental response to repetitive nerve stimulation
Single-fibre electromyography: Increased jitter
Anti-Jo antibodies: Negative
Anti-Mi2 antibodies: Negative
Anti-acetylcholine receptor antibodies: Negative

Which of the following immunological tests is most likely to contribute to the diagnosis?

MRCP2-3294

A 67-year-old man experiences left-sided hemiparesis and facial droop while shopping with his wife at 2:35 pm. A CT head scan is performed at 3:40 pm, which shows no intracranial haemorrhage or space occupying lesion. At 3:50 pm, he receives alteplase in the emergency department.

The next day at 9:00 am, a post-thrombolysis CT head reveals a right middle cerebral artery infarction with no evidence of intracranial haemorrhage or haemorrhagic transformation. An ECG done in the stroke unit shows atrial fibrillation with a heart rate of 110 beats per minute. He continues to have dense left-sided weakness several hours after thrombolysis.

What medication should be added to his treatment plan?

MRCP2-3295

A 65-year-old man came to the neurology clinic for evaluation. He had been experiencing progressive motor neuron disease for the past five years, resulting in significant weakness in all of his limbs and reliance on a wheelchair. He was taking baclofen for muscle spasms and amitriptyline to reduce salivation, but no other medications. He reported experiencing morning headaches that were throbbing in nature and not feeling refreshed after sleep.

During the examination, the patient exhibited general muscle wasting and fasciculations in all limbs. Reflexes were absent except for bilateral extensor plantar responses. Eye movements and fundoscopy were normal, and there were no significant issues with palatal movements or swallowing.

What intervention would likely provide the greatest survival benefit for this patient?

MRCP2-3296

A 67-year-old woman was admitted to a gynaecology ward for repair of a cervical prolapse. The operation went smoothly and she was up and about within two days. However, on the fifth day after surgery, she was found wandering in a confused state in the adjacent ward. She had been complaining of a throbbing headache for the past hour, but had otherwise been feeling fine. The confusion lasted for about two hours, during which she repeatedly asked, What am I doing here? She had no memory of the episode afterwards, but was able to resume normal conversation, although she needed to be reminded how long she had been in the hospital.

The patient had a medical history of hypertension, hyperlipidaemia, and migraine. She took regular atenolol and simvastatin, did not smoke, and did not drink alcohol. There was no family history of medical problems. On examination, she complained of a headache, but her vital signs were normal. Cranial nerve examination was normal, and there was no evidence of nystagmus. Peripheral nervous system examination, including plantar reflex responses, was normal. Chest and cardiovascular examination were entirely normal.

Investigations revealed a haemoglobin level of 112 g/L (normal range: 130-180), a white cell count of 11.3 ×109/L (normal range: 4-11), platelets of 245 ×109/L (normal range: 150-400), an ESR (Westergren) of 18 mm/1st hour (normal range: 0-15), a serum sodium level of 136 mmol/L (normal range: 137-144), a serum potassium level of 4.5 mmol/L (normal range: 3.5-4.9), a serum urea level of 4.2 mmol/L (normal range: 2.5-7.5), a serum creatinine level of 89 µmol/L (normal range: 60-110), a serum C reactive protein level of 15 IU/L (normal range: <5), and a urinalysis showing protein ++ and blood +. Based on the clinical account and investigations, what is the most likely diagnosis for this patient?