MRCP Part 2 Category: Neurology

MRCP2-3229

A 42-year-old woman arrives at the Emergency Department in the early hours of the morning with a 2-week history of progressive weakness in her arms and legs, preceded by a tingling sensation in her hands and feet. She describes the weakness as ‘slowly taking over me’. Over the last day, she has also noticed weakness in her face and difficulty making facial expressions. She reports experiencing shortness of breath, slurred speech, and difficulty swallowing food. She recently returned from a 3-month trip to South America and Africa, during which she had several episodes of diarrhea. The last episode occurred about 5 weeks ago, and she noticed blood in her stool. She has no significant medical history and is not taking any regular medications.

During the examination, she displays bilateral lower motor neuron VII nerve weakness and dysarthria. Her neck is weak, but there are no other significant cranial nerve signs. She has reduced power, particularly distally, with decreased ankle and knee jerks bilaterally. Plantar responses are absent. Sensory examination reveals decreased soft touch and pinprick sensation in her hands and feet.

What is the most appropriate initial management step?

MRCP2-3245

A 25-year-old woman was referred to neurology clinic by her family. She has been experiencing repetitive movements of her shoulders and hands for the past year. Initially, the movements were infrequent, but now they occur every few minutes. The movements are stereotyped and involve a brief shrug of the shoulders and clapping movement of the hands. During these episodes, she remains fully conscious but sometimes mutters inappropriate words. This has caused her to lose her job and struggle in social situations. She has no significant medical history and has reached all developmental milestones. As a child, she was very organized and would arrange her toys in a specific way. She has been under a lot of stress and has lost weight in the past year. On examination, she appears anxious and continuously rubs her coat sleeve. Several movements occur affecting her shoulders and hands, lasting a few seconds. When asked about the movements, she becomes more anxious and simply states that she has to do them. Cranial nerve examination is normal, but testing power results in increased anxiety followed by multiple arm movements. Cardiovascular, chest, and abdominal examinations are all normal. A CT scan of the brain is normal. Hemoglobin, white cell count, and platelets are within normal range. Serum sodium, potassium, and urea are also within normal range. Serum copper is low, and serum caeruloplasmin is normal. Based on this clinical account and the results of the investigations, what is the likely diagnosis?

MRCP2-3230

A 63-year-old man, who is right handed, was brought to the Emergency department after collapsing at home. He has a history of hypertension but has not been compliant with therapy. Upon examination, his Glasgow coma scale (GCS) score was 15/15 and his blood pressure was 142/95 mmHg. He had significant weakness on his right side, with a grade 1/5 in his upper and lower limbs and an extensor right plantar response. A CT scan of his head revealed a left intracerebral frontoparietal haematoma. Two hours after his admission, he remained stable.

What is the most appropriate management plan for this patient?

MRCP2-3246

A 63-year-old man is experiencing difficulty walking. He has a medical history of diabetes mellitus and cervical spondylosis, for which he underwent surgical decompression eight years ago. Additionally, he consumes 40 units of alcohol per week.

During examination, the patient exhibited fasciculation, wasting, and weakness in the left deltoid and biceps, as well as weakness in the shoulder girdle muscles on both sides. There was also fasciculation in the glutei and quadriceps bilaterally, weakness in hip flexion and foot dorsiflexion, brisk reflexes in the upper and lower limbs, and extensor plantar responses. No sensory impairment was detected.

What is the likely diagnosis for this patient?

MRCP2-3231

A 45-year-old hiker presents with flu-like symptoms and a right Bell’s palsy. She is seen by his family doctor and prescribed oral corticosteroids. She has recently returned from a four-week trip to South Germany. A week later, she returns, complaining that the facial weakness is now affecting both sides of her face and she feels weakness in her right arm. On examination, she has a temperature of 37.8 °C and a blood pressure of 120/70 mmHg. Her lungs are clear, and there are no heart murmurs. Her abdomen is soft and non-tender. She has a significant right facial palsy and minor facial weakness on the left side. There is also weakness in her right arm. Routine blood tests are normal.

What is the most appropriate next step?

MRCP2-3232

A 50-year-old right-handed man presents with sudden onset of headaches, dysphasia and right sided weakness.

Three months ago, he had undergone debulking surgery for advanced carcinoma of the colon. During clinical examination, enlarged inguinal lymph nodes, hepatomegaly, right hemiparesis and expressive dysphasia were observed.

Further investigations revealed a normal chest x-ray. A CT brain scan showed three small lesions throughout the cerebral hemispheres and one large hyperdense lesion in the left parietal region.

What would be the most appropriate course of action for this patient?

MRCP2-3233

A 32-year-old man presents with a two-year history of weakness and wasting in his distal extremities. He reports difficulty releasing his grip when shaking hands. On examination, he has a long, expressionless face with mild bilateral partial ptosis and cataracts. He also exhibits a slow gait and bilateral foot drop. Cardiovascular and respiratory exams are unremarkable. Laboratory results show normal FBC and U+Es, but elevated plasma glucose at 15.5 mmol/L (3.0-6.0).

What is the most appropriate management step for this patient?

MRCP2-3234

An 82-year-old man comes to the hospital complaining of increasing confusion, urinary incontinence, and falls over the past three months. A confusion screen is conducted, and blood tests reveal low B12 levels, but are otherwise normal. CT brain scan shows enlarged ventricles, and a lumbar puncture is performed, revealing normal CSF with an opening pressure of 15 cmH2O. The patient’s symptoms improve slightly after 30 mls of CSF are removed. What is the most definitive course of action for treating this patient?

MRCP2-3235

A 25-year-old man with a history of epilepsy presents to the Emergency department after experiencing a series of tonic-clonic convulsions at home. He is currently taking sodium valproate as his only prescribed medication. Upon examination, he is found to be unconscious and having continuous seizures. To maintain his airway, he is placed into a lateral position and given 10 L/min of oxygen via a high-flow mask. Intravenous access is established and he is given intravenous lorazepam, but continues to have seizures. Two more boluses of lorazepam are given at five-minute intervals, but he experiences another generalised convulsion 30 minutes later. What should be the next course of action?

MRCP2-3236

A 30-year-old female presents to the Emergency Department with progressive weakness in her lower limbs over the past three days. She is now unable to walk and has noticed clumsiness in her fingers. Upon examination, her heart rate is regular at 65 beats per minute, blood pressure is 125/70 mmHg, and respiratory rate is 20 breaths per minute. Ankle and knee jerks are absent, and upper limb reflexes are reduced.

Based on her likely diagnosis, what is the most important parameter to monitor throughout her hospitalization?