MRCP Part 2 Category: Neurology

MRCP2-3252

A 50-year-old female presents to the neurology clinic with complaints of fatigue and muscle weakness, specifically in the lower limbs, which is causing difficulty walking. The patient has experienced similar episodes in the past, with one episode resulting in painful, reduced visual acuity. These episodes typically last a few weeks before resolving on their own.

During the examination, the patient exhibits spasticity weakness in the lower limbs with reduced sensation distally. Cranial nerve and spinal examinations are normal. An MRI of the brain reveals disseminated brain lesions, and further testing confirms unpaired oligoclonal bands in the CSF, but not in the serum.

Which of the following factors is associated with a poor prognosis in the patient’s most likely diagnosis?

MRCP2-3237

A 65-year-old retired accountant was referred to the neurology clinic by his GP due to a three-month history of malaise and weakness. Initially, he experienced weakness in his legs, but over the last month, he also noticed weakness in his hands, especially his left hand. His speech had also changed in tone. He had a medical history of hypertension, hypercholesterolaemia, depression, and hypothyroidism. On examination, he appeared cachectic with obvious dysarthria. Investigations conducted by the GP prior to referral showed anemia, thrombocytopenia, leukocytosis, and positive ANA. Which intervention is most likely to be beneficial for this patient?

MRCP2-3238

A 70-year-old male visits the Parkinson’s clinic with his spouse, complaining of more frequent and longer ‘off’ periods. The couple finds these episodes highly debilitating and occur up to 10 times a day. The patient was diagnosed with Parkinson’s disease 10 years ago. As a relatively young patient on diagnosis, he was started on ropinirole, which he continued for 4 years, before being prescribed Sinemet 5 times a day and entacapone for the following 6 years. Over the last 2 years, the ‘off’ episodes have gradually increased in frequency, along with the development of very mild involuntary jaw movements. He is feeling very low and has been to the emergency department twice with attempted paracetamol overdoses. He would like a more effective treatment. What treatment plan would you suggest?

MRCP2-3239

A 30-year-old woman who is 34 weeks pregnant and has a history of pregnancy induced hypertension presents to the Emergency Department after experiencing headaches and a seizure at home. Upon arrival, she has neurological symptoms indicative of an intracerebral bleed and a blood pressure reading of 195/85 mmHg.

What is the best immediate action to take in this situation?

MRCP2-3240

You encounter a 45 year-old man who has been referred to the neurology clinic by his GP.

He reports experiencing facial pain for the past year. The pain is particularly severe when he is shaving or brushing his teeth, and he describes it as a ‘stabbing’ sensation that goes through the teeth of his upper jaw and over the right side of his face. Despite seeing multiple dentists and having several teeth removed, he has not found any relief. The pain has been progressively worsening, and whereas before it occurred in distinct episodes, it now occurs almost constantly. He has read various online sources and has become convinced that he has a brain tumor, which has caused him to become depressed and withdrawn.

His medical history includes essential hypertension, for which he takes perindopril. He also has a history of sinusitis and has undergone sinus washouts on multiple occasions. Two years ago, while on a business trip abroad, he experienced vision problems in his left eye that resolved spontaneously over a few weeks, and for which he did not seek medical attention.

Upon examination, there are no notable findings. Cranial nerve examination is mostly normal, but you observe a patch of numbness on the right cheek. Muscle strength is 5/5 in all limb groups, reflexes are normal, and plantar responses are downward. Sensation in the limbs is normal.

What is the most appropriate course of action?

MRCP2-3241

A 35-year-old woman presented to the Outpatient Clinic with a history of recurrent headaches for the last 6 months. These occur up to four times per day and last 20–40 min each time. She described two periods during these 6 months, one lasting 3 weeks and the other lasting 5 weeks, when the headaches occurred and that she had been headache free in between these times. She described experiencing severe left-sided pain behind the eye and she often noticed that the left eye became red and teary.

On examination, her BP is 118/70 mmHg, pulse is 72 bpm and regular and her BMI is 23. Physical examination, including full neurological exam, is entirely normal.

Which one of the following medications is most likely to be effective in preventing future headaches?

MRCP2-3242

What is the probable diagnosis for a 29-year-old man who had a right-sided middle cerebral artery territory infarct and has a history of focal impaired awareness seizures, difficult-to-treat migraines, recurrent vomiting, tremors, and muscle weakness with atrophy?

MRCP2-3243

A 59-year-old male presents with his fourth episode of binocular visual phenomenon over the past 10 months. He describes these episodes as ‘lights’ and ‘white dots’ in his field of vision. He denies any limb or facial weakness or sensory loss. He denies having a headache. He is an active smoker, with a 50 pack year smoking history and has known hypertension on ramipril 5mg OD. Your neurological exam is unremarkable; CT head demonstrates no acute infarct or haemorrhage. MRI head is unremarkable.

What is the most likely diagnosis?

MRCP2-3228

A 32-year-old woman, who is 30 weeks’ pregnant, presents to the GP complaining of her left foot dragging and tripping her up, particularly when she walks up stairs. Previously her health has been very good, with only mild allergies managed with loratadine.
On examination she looks well, with a BP of 110/70 mmHg; neurological examination reveals mild foot drop consistent with a left common peroneal nerve palsy.
Investigations reveal the following:

Haemoglobin (Hb) 120 g/l 130–170 g/l
White cell count (WCC) 6.2 × 109/l 4.0–11.0 × 109/l
Platelets (PLT) 250 × 109/l 150–400 × 109/l
Sodium (Na+) 142 mmol/l 135–145 mmol/l
Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
Creatinine (Cr) 75 μmol/l 50–120 µmol/l
Erythrocyte sedimentation rate (ESR) 8 mm/hour < 10mm/hour
C-reactive protein (CRP) < 5 mg/l < 10 mg/l
ANCA Negative
Which of the following is the most appropriate management step for this patient?

MRCP2-3244

A 43-year-old male presents with weakness in his fingers and double vision, which he noticed when he repeatedly dropped his pen whilst trying to write at work. His symptoms appear to have onset over the past few days. He had a recent episode of diarrhoea and vomiting about three weeks ago. He denies any limb weakness and sensory loss. There is no back pain or palpitations. On examination, there is a 3/5 weakness in finger flexion, finger extension and wrist extension in both hands, with no fatigability. No reflexes present in the lower or upper limbs. There is no ptosis or nystagmus but reduced eye movements in all directions. His finger-nose test demonstrates reduced coordination bilaterally and the patient has too little confidence to walk. What investigation is most likely to provide a diagnosis?