MRCP Part 2 Category: Neurology

MRCP2-3273

A 65-year-old man presents with a six month history of progressive unsteadiness. He reports an irregular swaying gait with a tendency to veer to the left when walking. His wife notes that he stands with his feet apart. He also complains of urinary urgency and frequency, despite multiple negative urine tests. He attributes occasional muscle stiffness to aging.
On examination, his pulse is 70 beats/min, BP 135/80 mmHg supine, 105/55 mmHg standing. There is increased tone in opposing muscle groups when joints are passively moved, but no muscle wasting or weakness. Gait is broad-based with a leftward lean. Reflexes are brisk and plantar responses are downgoing bilaterally. Finger to nose testing is impaired in the upper limbs. Sensory exam is normal.
What is the likely diagnosis?

MRCP2-3274

A 45-year-old man presented to the cardiologists with heart failure. His ECG revealed atrial fibrillation with a rate of 130 bpm. He was given diuretics and underwent cardioversion with amiodarone. During his hospital stay, the nurses observed him bumping into objects on the ward. Upon examination, it was discovered that he had severe visual impairment. However, when asked directly, he denied any loss of vision and insisted that he could see everything around him. A CT scan of his head showed bilateral occipital infarcts. What is his diagnosis?

MRCP2-3275

A 30-year-old woman presents with a gradual loss of central vision in both eyes over two days, accompanied by pain when moving her eyes. Within 24 hours, she experiences tingling sensations in both arms and weakness in both arms. Upon examination, she displays a central scotoma in both eyes, as well as a 3/5 global weakness in both arms, hyperreflexia, and patchy sensory loss. Over the next few days, she develops paraesthesia and weakness in both lower limbs, along with extensor plantar responses. Which elevated serum levels would be most useful in confirming the suspected underlying diagnosis?

MRCP2-3276

A 65-year-old male presents to the Emergency Department with altered sensation in both hands and reduced visual acuity in the left eye. He reports that these symptoms have gradually worsened over the past week. He denies any issues with bladder or bowel function.

Upon examination, the patient is stable hemodynamically. Notably, he has a sensory loss throughout his arms and legs, but no clear sensory level. He also has brisk reflexes in both upper and lower limbs. His left eye has a visual acuity of 6/36, while his right eye has normal vision with normal visual fields.

An MRI scan reveals multiple continuous segments of inflamed spinal cord throughout the cervical region and left optic nerve inflammation. There are no cerebral lesions. The patient’s cerebrospinal fluid (CSF) studies are negative for oligoclonal bands.

What test is necessary to confirm the diagnosis?

MRCP2-3277

A 35-year-old man is brought to the Emergency department following a car accident. As the attending physician, you are asked to assess the patient.

Upon examination, the patient is alert and oriented to time, place, and person. However, he cannot recall any details about the accident except for getting into the car to attend a meeting at 9 am. According to the paramedics who responded to the emergency call, the patient was involved in a frontal car collision and was found outside the car at 9:45 am. He was initially disoriented but regained his senses after a few minutes.

The patient has only minor injuries, including superficial scratches and bruises on his face, elbows, and knees, as well as a small hematoma on his forehead. His Glasgow Coma Scale (GCS) score is 15, and he is able to move around and is eager to leave the hospital.

As the physician in charge, what would be your recommended course of action for managing this patient?

MRCP2-3278

A 73-year-old man was admitted with a cough productive of green phlegm, shortness of breath and a low-grade fever. Past medical history included Parkinson’s disease for which he was on co-careldopa and hypertension. Chest x-ray showed a right basal consolidation and he was treated for pneumonia with oral antibiotics. As a result of the pneumonia he had a poor appetite and the patient had been refusing to take his medication.

He was given intravenous fluids and encouraged to take his oral antibiotics. Over the next 1-2 days, the nurses noted that he had started to have fever spikes of greater than 38ºC, had developed a tremor and was becoming increasingly rigid, agitated and confused. His blood pressure had also been extremely variable.

What diagnostic test would help confirm the diagnosis?

MRCP2-3279

A 35-year-old man presents to his doctor with recurrent severe pain behind his right eye that has been occurring at night for the past week. He has experienced approximately eight attacks and reports that the pain lasts for about 90 minutes each time. During an attack, his right eye becomes watery and red, and he has vomited several times due to the pain. He is a smoker and drinks alcohol regularly. On examination, he appears flushed and in distress, with a right ptosis and miosis and some right conjunctival injection. His blood pressure is elevated, and his arteries are pulsatile but non-tender. Laboratory tests reveal no significant abnormalities. What is the best treatment to give during an acute episode?

MRCP2-3280

A 32-year-old woman has been referred to the first fit clinic after experiencing a seizure three weeks ago. Her boyfriend witnessed the seizure, which lasted for approximately three minutes and involved violent shaking of her arms and legs. He also noted laboured breathing, blood in her mouth, and incontinence of urine. The day before the seizure, she had consumed one bottle of champagne and felt tired before going to bed. She has a history of asthma and frequent headaches, for which she takes sumatriptan and a salbutamol inhaler as needed. She is a smoker and drinks approximately 20 units of alcohol per week. She works in publishing and holds a driving license.

On examination, her blood pressure is 120/80 mmHg, pulse is 67 beats/minute, and neurological system is normal. Investigations reveal abnormal liver function tests, with elevated gamma GT, alkaline phosphatase, and alanine aminotransferase levels.

What would be the next step in managing this patient?

MRCP2-3265

An 80-year-old male with a history of atrial fibrillation, ischemic heart disease, and hypertension is brought to the hospital by his daughter who is worried about his declining health. Over the past few weeks, the patient has been experiencing more difficulty with balance, resulting in falls at home. Additionally, his daughter has noticed that he has become more forgetful and less engaged in his usual hobbies. When asked about his symptoms, the patient expresses concern about recent urinary incontinence, which he finds embarrassing.

As part of the diagnostic workup for this patient, a CT scan of the head is ordered. What is the most probable finding?

MRCP2-3281

A 67-year-old man presents to the Emergency department with confusion. His wife reports that he has been acting strangely for the past two days, experiencing difficulty with his clothing and making unusual swallowing movements. He has also had several episodes of twitching in his right hand and speech impairment. The patient has a medical history of type II diabetes, hypertension, and partial epilepsy. He takes metformin, bendroflumethiazide, phenytoin, and carbamazepine regularly. He is a smoker and drinks alcohol occasionally. On examination, he appears confused with a Glasgow coma scale of 13/15. His blood pressure is elevated, and he has subtle nystagmus and increased tone in his right upper limb. Chest and cardiovascular examination reveal left basal crackles. Investigations show multiple periventricular ischaemic white matter changes on a CT scan of the brain. How would you manage this patient?