A 55-year-old man with learning difficulties presents with urinary incontinence and difficulty managing household tasks. He has a history of losing his son to multiple sclerosis. On examination, he has poor short and long term memory, labile affect, and difficulty interpreting proverbs. He also exhibits horizontal nystagmus, past-pointing in the upper limbs, and difficulty with heel-to-toe walking in the lower limbs. Brisk deep tendon reflexes and extensor plantar responses are present. What is the probable diagnosis?
MRCP2-3214
A 55-year-old man with learning difficulties presents with urinary incontinence. He lives alone and has been struggling with simple household tasks like cooking and cleaning for the past two months. He reports difficulty with concentration and memory. His son passed away from complications of multiple sclerosis.
During examination, he was oriented in time, place, and person but had difficulty with recall and long-term memory. He also had labile affect and difficulty interpreting proverbs. Cranial nerve examination was unremarkable except for bilateral horizontal nystagmus on lateral gaze. Limb examination revealed past-pointing in the upper limbs, difficulty with heel-to-toe walking in the lower limbs, brisk deep tendon reflexes, and extensor plantar responses. Bilateral palmomental reflexes were present.
What treatment plan would you recommend for this patient?
MRCP2-3215
A 70-year-old man has been experiencing progressive weakness in his lower limbs for the past four months. He finds it difficult to get up from his armchair and walk, and tires easily during any activity. He has also been experiencing a dry mouth and constipation, which is sometimes painful and incomplete.
His GP has identified a positive faecal occult blood sample and he has lost 3 kg in weight over the past 2 months. On examination, his blood pressure was 180/90 mmHg, heart rate 102/min. There was no clubbing or skin rash. His BMI was 24. He was alert and cognition was normal. Pupils were 2.5 mm on each side and were non-reactive to light. He also had slight bilateral ptosis. Other cranial nerves were normal. Hip flexors were 4/5. His grip strength also appeared weak bilaterally, but improved with reinforcement. Tendon reflexes were symmetrical and hypoactive. Planters were flexors. No muscle tenderness was present.
What is the most likely diagnosis?
MRCP2-3216
A 65-year-old man comes to the emergency department with a complaint of gradual slurring of speech over several months. Upon examination, he displays proximal muscle weakness that improves with repetition and a bulbar palsy. He appears frail and emaciated. What is the probable diagnosis?
MRCP2-3217
A 67-year-old man presents to a neurologist with weakness in his left foot. He reports stubbing his toes while walking and experiencing numbness in his entire left foot and up the back of his thigh. He denies any back pain or issues with bowel or bladder function. The patient has a history of diabetes and hypertension and takes metformin, gliclazide, and ramipril. He also smokes 10 cigarettes per day and drinks four pints of beer on the weekends.
On examination, there is evidence of wasting in the left anterior compartments of the lower leg and mild wasting of the hamstrings. The left ankle has significantly reduced tone and the left foot has flaccid tone. The patient exhibits marked weakness in foot dorsiflexion, plantar flexion, eversion, and inversion, as well as additional weakness in left hip extension and knee flexion. There is an absent ankle and plantar response on the left with all other reflexes intact. Sensory examination reveals reduced sensation to all modalities over the entire posterior left lower leg and the back of the left thigh.
What is the likely location of the lesion in this patient?
MRCP2-3218
A patient suffering from focal epilepsy that is not responding to two medications is prescribed levetiracetam. What is the most crucial adverse effect that patients starting this medication should be cautioned about?
MRCP2-3219
A 50-year-old woman has experienced weight loss over the past six months. Her family has noticed that she has become forgetful over the last two months, struggling to remember things like phone numbers or her daily activities. She has recently had a second episode of what appears to be a generalized tonic-clonic seizure within the last week. She has no significant medical history. Upon examination, she has a MMSE score of 23/30, appears cachectic, has a bulky left adnexal region, and no other notable findings. Routine blood tests are normal. A CT scan of the chest, abdomen, pelvis, and head reveals a suspicious lesion in the left ovary but is otherwise unremarkable. A biopsy of the left ovary is ordered, along with a paraneoplastic blood screen and an MRI of the brain. What results would you anticipate from the paraneoplastic screen?
MRCP2-3220
A 40-year-old man presents to the hospital with sudden onset quadriparesis and complete loss of speech. His partner reports that he had been feeling well prior to the event and had not complained of any symptoms. The patient has a history of frequent cocaine use and occasional heroin injection. On admission, he has a Glasgow coma scale of 3/15 and pinpoint pupils with oculoparesis. Neurological examination reveals generalised hypertonia and hyperreflexia with bilateral extensor plantar responses. He is intubated and taken to intensive care. After four weeks of extensive investigation, he regains consciousness but exhibits decerebrate rigidity and is unable to speak or make any purposeful response. What is the most likely cause of his condition?
MRCP2-3205
A 29 year old woman with relapsing-remitting multiple sclerosis (MS) has come to your clinic seeking advice on how pregnancy may affect her condition. She was diagnosed at age 20 and has been managed on interferon β 1a, with only four relapses in her total history. Despite mild dysdiadochokinesis of the left arm, she scores functionally very well on an expanded disability status scale (EDSS) and has no disability as a result. She is planning her first pregnancy and has already been advised to stop interferon β 1a in preparation. Apart from the impact of stopping the medication, she wants to know how pregnancy itself will affect her MS. What is the most accurate response?
MRCP2-3206
A previously healthy 68 year old patient presents to the emergency department with a sudden onset of weakness. The patient’s spouse called 911 immediately upon noticing the weakness.
Neurological examination:
CN I-IV normal CN V ophthalmic and maxillary divisions normal with reduced sensation in mandibular division on left side CN VI normal CN VII reduced power to left lower facial musculature CN VIII normal CN IX, X and XII weakness in swallow CN XI weakness on turning the head to the left.
Right upper limb normal tone, power 5/5, normal reflexes and sensation. Normal finger pointing. Left upper limb markedly increased tone, power 1/5 globally in all muscle groups, brisk reflexes and reduced sensation to light touch. Unable to move limb to determine ability to finger pointing.
Right lower limb normal tone, power 5/5, normal reflexes and sensation. Heel-knee-shin test normal. Left lower limb slightly increased tone, power 3/5 globally, brisk reflexes and reduced sensations. Reduced ability to heel-knee-shin test when compared to right side.
Gait – not assessed due to weakness. Romberg’s test – not done due to weakness.