MRCP Part 2 Category: Neurology

MRCP2-3260

A 32-year-old woman is referred by her GP for neurological evaluation of muscle weakness and stiffness. Her mother also had similar problems and had died due to respiratory failure. She also gives a history of progressive visual impairment of a few years’ duration. The other problem is recurrent dislocation of her shoulder. She is a known diabetic on insulin and has recently attended the endocrinologist for evaluation of infertility.

On examination, she has bilateral cataracts, bilateral mild ptosis is evident and there is frontal balding. Ocular movements are normal but there is wasting of the temporalis, masseter and sternocleidomastoid muscles on both sides. Muscles of both hands are wasted and both wrists are weak. When you shake her hand she can only slowly relax her grip. There is bilateral foot drop and tendon reflexes are reduced.

What is the most likely diagnosis for this patient?

MRCP2-3261

A 38-year-old woman has been diagnosed with relapsing remitting multiple sclerosis and is exploring further treatment options, including natalizumab. Despite receiving glatiramer acetate, she has experienced two severe relapses. Although she is still able to work, she feels fatigued and has limited mobility.

During her examination, the woman displays brisk reflexes bilaterally, with mild weakness in her proximal left leg and reduced sensation in her left foot. Her brain MRI reveals highly active disease with multiple acute and subacute plaques, as well as a single lower cervical cord lesion.

Before considering a new therapy, which investigation result is of the utmost importance, aside from HIV and general immunological status?

MRCP2-3262

A 25-year-old female with multiple sclerosis (MS) presents to the emergency department after experiencing a seizure. She was diagnosed with MS at age 20 and has been on various immunomodulatory treatments, including azathioprine. She started natalizumab therapy 3 years ago. This is her first seizure, but she reports feeling increasingly clumsy over the past 8 months and has had several instances of slurred speech where people have commented that she sounds tired.

During the examination, her muscle tone is normal, and she has normal power in all muscle groups in both upper and lower limbs. However, a right homonymous superior quadrantanopia is identified, although she has full eye movement and no ptosis. She also has an ataxic gait, but her speech is normal.

The patient is worried and asks for a diagnosis. What is your assessment?

MRCP2-3247

A 46-year-old male patient complains of gradual weakness in his hands for the past nine months. Upon examination, there is muscle wasting and fasciculations in his upper limbs. His lower limb reflexes are brisk and planters are upgoing, while his sensation is normal. What is the probable diagnosis for this patient?

MRCP2-3263

A 28-year-old woman presents to her GP with complaints of experiencing tunnel vision episodes. These episodes occur while she is at work and are preceded by dizziness and fatigue. The tunnel vision lasts for several minutes and is sometimes accompanied by dark holes in her visual range. After an episode, she feels anxious and develops a headache. She has had approximately six episodes in the past month.

The patient has a medical history of type 1 diabetes, which is controlled with TDS insulin. She takes co-codamol for headaches and has a family history of glaucoma. She is a smoker and drinks approximately 20 units of alcohol per week. She works as a legal secretary and admits to experiencing work-related stress.

During the examination, her blood pressure was 139/89 mmHg, and her pulse was 89 beats per minute. Fundoscopy revealed scattered cotton-wool spots, and there were no other cranial nerve abnormalities. Her peripheral nervous system examination was normal, except for some diminished pin prick sensation over the dorsum and soles of both feet.

Investigations revealed a glucose level of 8.9 mmol/L (3.0-6.0) and an HbA1c level of 74 mmol/mol (<42) or 8.9% (<6%). An electrocardiogram showed a heart rate of 88 beats/min in sinus rhythm. What is the most likely cause of this patient’s symptoms?

MRCP2-3248

A 42 year-old man presents to the neurology clinic with complaints of weakness in his right hand, making it difficult to perform tasks such as writing and dressing. He has also noticed twitching in his right forearm and hand. The patient cannot recall exactly when the symptoms first began but feels that they have been present for at least six months and have worsened over time.

The patient has a history of well-controlled asthma but is otherwise healthy. There is no family history of neurological disease.

During the examination, the cranial nerves appear normal. However, weakness of extension of the middle and ring fingers (2/5 on the MRC scale) is observed in the right hand, along with visible fasciculations in the dorsal aspect of the forearm. The left hand also shows some subtle weakness of extension of the ring finger (4/5 on the MRC scale), but no muscle wasting is discernible. There is no weakness of wrist extension on either side, and power in all other muscle groups is normal. All fingers extend when the wrist is passively moved into palmar flexion. Reflexes are normal, and there are no sensory signs.

What is the most likely diagnosis?

MRCP2-3264

A 36-year-old male patient complains of progressive memory impairment for the past six months. During the examination, he displays involuntary jerking movements in his limbs. The EEG results reveal biphasic high-amplitude sharp waves. What is the probable diagnosis?

MRCP2-3249

A 58-year-old construction worker presents to the neurology clinic with a history of weakness and clumsiness in his right arm and hand for the past four months. He has noticed a significant reduction in dexterity and grip strength, leading him to give up his job. He denies any sensory changes in the affected limb. His medical history includes asthma, osteoarthritis, and hypertension. He smokes 10 cigarettes per day and drinks 21 units of alcohol per week. On examination, there is mild wasting of the right dorsal interossei and thenar muscles, with fasciculations present. Power is significantly reduced in right finger flexion/extension, thumb abduction and opposition, and wrist flexion/extension. Reflexes are asymmetrically depressed on the right, but sensation is intact in both arms. Lumbar puncture reveals normal CSF parameters, and MR cervical spine shows degenerative joint disease affecting C3-6 vertebrae. EMG shows fasciculations affecting dorsal and palmar interossei, with patchy block of motor nerve conduction innervating fasciculating muscles. Sensory conduction is normal. What is the likely diagnosis for this patient?

MRCP2-3250

A 63-year-old man presents with symptoms of paraesthesia and numbness in both lateral aspects of the hands over the past year. He has also experienced weakness when using his thumbs and has noticed a decrease in appetite, resulting in weight loss over the last six months. Additionally, he has been experiencing episodes of nighttime diarrhea and increased urinary frequency. He has a history of hypertension and takes bendroflumethiazide and ramipril. He is a smoker and drinks alcohol weekly. He works as a carpenter and has a family. On examination, he has sensory loss over the lateral three and a half fingers bilaterally, weakness of the thenar muscles, and loss of sensation in both feet. Ankle jerks are absent and plantar responses are equivocal. Based on these symptoms, what is the most likely diagnosis?

MRCP2-3251

A 38-year-old woman with relapsing-remitting multiple sclerosis on natalizumab presents with left leg weakness that progresses to left hemiparesis and visual impairment over 3 weeks. She also experiences memory difficulties and struggles with numbers at work as an accountant. On examination, she has 4/5 power on the left side, right homonymous hemianopia, and an abbreviated mini-mental state score of 21/30. Routine blood tests are normal. MRI brain shows multiple confluent lesions in the parieto occipital and right motor white matter areas, as well as the left occipital area, without mass effect or enhancement. Which test would be most useful in establishing a diagnosis?