A 55-year-old man presents to the emergency department with a 2-day history of bilateral leg weakness. He is having difficulty standing up from a chair and has also noticed finger paraesthesia.
The patient has no significant medical history, but reports recent diarrhoea. He is a smoker and drinks up to 4 pints of beer most nights. He works as a plumber.
On examination, there is marked weakness in the lower limbs, absent reflexes, and dysarthria. A bedside swallow assessment reveals significant coughing. An MRI of the whole spine is normal, but blood tests show a raised ALT.
Assuming standard treatment, what is the likelihood of long-term weakness given the likely diagnosis?
MRCP2-3222
A 50-year-old man with a history of hypertension and ischemic heart disease presents to the emergency department after collapsing. He experienced weakness on his left side before suddenly falling to the ground. His partner reports that he was unconscious for approximately two minutes and noticed that the right side of his face drooped. However, the patient’s symptoms resolved entirely after an hour.
Given the patient’s medical history and symptoms, what aspect of his history indicates that an alternative diagnosis is more probable than a TIA?
MRCP2-3223
A 26-year-old woman presents to the neurology outpatient clinic with a history of idiopathic intracranial hypertension and recurring headaches. She is currently taking acetazolamide. Upon examination, papilloedema is observed during fundoscopy, and her body mass index is 31 kg/m². Her visual acuity is normal. To address her condition, a therapeutic lumbar puncture is performed in the left lateral position, during which 10 ml of cerebrospinal fluid is removed and an opening pressure of 29 25 cmCSF is recorded. Unfortunately, the patient develops a headache following the procedure. What could have been done to reduce the likelihood of this complication?
MRCP2-3224
A 65-year-old man presented to the Emergency department with weakness and excruciating pain in his right lower limb. The weakness and pain had progressively worsened over several weeks, to the point where he was wheelchair bound. He did not complain of any back pain, but had noticed increased urinary frequency and hesitancy.
He had a medical history of diabetes and hypertension, and regularly took metformin and ramipril. He was a smoker of 20 cigarettes per day and drank six units of alcohol per week.
On examination, he appeared in some distress. There was evidence of right leg oedema, and the leg itself appeared warm and dry to touch. Tone was diminished at the hip, knee, ankle, and foot, and there was evidence of wasting over the anterior and posterior compartments of the right lower leg. There was 3/5 power of hip flexion, extension, and adduction, with marked weakness of knee flexion, dorsiflexion, plantar flexion, eversion, and inversion. The knee, ankle, and plantar reflexes were all absent. On testing sensation, there was diminished pinprick over the toes, extending to the perianal area in the right leg. The left leg appeared normal.
A 35-year-old woman presents to the neurology clinic with flu-like symptoms, double vision, and facial weakness that have been ongoing for four days. She reports experiencing double vision when looking to the right and is unable to fully close her eyes. The patient recently returned from a camping trip in the New Forest six weeks ago. She has a medical history of type I diabetes, which was diagnosed when she was eight years old, and takes regular insulin injections.
During the examination, the patient appeared alert and oriented. She complained of arthralgia in her hands and knees. Her blood pressure was 130/75 mmHg, pulse was 70/min and regular, temperature was 37.4°C, and blood glucose monitoring was 4.7 mmol/L. There was no evidence of rash or neck stiffness.
On cranial nerve examination, fundoscopy was normal, and both pupils were equal and reactive to light. Ocular movement testing revealed oculoparesis of the right lateral rectus. Bilateral facial weakness with bilateral Bell’s phenomenon was also observed. Examination of the peripheral nervous system did not reveal any abnormalities.
A lumbar puncture was performed, and the results showed an opening pressure of 13 cmH2O (5-18), CSF protein of 1.3 g/L (0.15-0.45), CSF white cell count of 120 per ml (<5), CSF white cell differential of 90% lymphocytes, CSF red cell count of 4 per ml (<5), and CSF glucose of 3.9 mmol/L (3.3-4.4). CSF oligoclonal bands were present, while serum oligoclonal bands were negative.
An MRI scan of the brain revealed multiple periventricular white matter lesions. Based on the patient’s history and clinical findings, what would be the appropriate management plan?
MRCP2-3210
A 14-year-old boy comes to the clinic with a history of a single seizure that occurred without warning after a family gathering. Upon further questioning, he reports experiencing episodes of blank spells for the past six years and brief shock-like contractions of his upper limbs several times a month, particularly during breakfast. There are no significant medical or family histories, and physical examination is unremarkable.
Which statement about the patient’s condition is false?
MRCP2-3226
A 63-year-old man presents to the Emergency department with sudden onset right-sided weakness lasting approximately 20 minutes. He had a similar episode the week before lasting approximately 10 minutes. He is a smoker of 15 cigarettes/day and takes bendroflumethiazide 2.5 mg/day for hypertension. On examination, his blood pressure is 140/98 mmHg, pulse is 65 and irregularly irregular, and heart sounds are normal. He has a left carotid bruit. A CT scan with contrast did not show any abnormalities. Investigations reveal a 75% stenosis of the left external carotid artery. Which of the following options offer the best way of managing this patient?
MRCP2-3211
A 20 year old woman comes to the general medical clinic for evaluation. She has been referred due to drooping of her eyelids, first on the left and now bilaterally. Upon further questioning, she reports difficulty reading in low light and mentions that two family members have had to undergo cardiac pacemaker placement. During the examination, partial bilateral ptosis and a generalized ophthalmoplegia in all directions of gaze are observed. Fundoscopy reveals central areas of dark pigmentation on a pale fundus.
Which investigation is most likely to lead to a diagnosis?
MRCP2-3227
A 68-year-old right-handed man is referred to the Stroke Unit. He is a lifelong heavy smoker but has no past medical history. He reports sudden onset facial paralysis that has persisted for a day. He also notes that sounds seem louder on the left side.
Upon examination, there is flattening of the nasolabial fold on the left, and he is unable to raise his eyebrow or close his eye on that side. His blood pressure is 160/80 mmHg. There is no rash or adenopathy. The rest of his neurological examination, including auroscopy, assessment of parotids and mucous membranes, is normal.
What is the most appropriate management plan for this patient?
MRCP2-3212
You are presented with a 19-year-old female who has limited eye movements and progressive muscle weakness. When she was 7 years old, she experienced double vision that eventually resolved. However, in her early teens, she found it difficult to keep up with other children during playtime. Over the past year, her double vision has returned and she has noticed a gradual weakening of her muscles, making it challenging to stand up from a seated position.
During the examination, you observe that she is of short stature and has ptosis, as well as a lack of spontaneous facial expressions. Her mental status examination is normal, but her eye movements are absent in all directions. Her pupils respond to light, but her visual acuity is reduced even with correction. The fundi show pigmentary degeneration, but there are no cataracts present. Her hearing is normal.
Upon conducting a motor examination, you discover that she has weak neck muscles and proximal muscle groups in her lower extremities. Her deep tendon reflexes are reduced, and her plantar reflexes are flexor. Cerebellar testing reveals intact finger to nose, slow rapid alternating movements in the upper extremities with mild ataxia, moderate heel to shin ataxia, and gait ataxia. Romberg’s testing is steady with eyes open and closed. Sensory examination shows preserved sensation to all primary modalities. The rest of the systemic examination is unremarkable, but her ECG shows incomplete heart block.
Which diagnostic test would be the most beneficial in establishing a diagnosis?