MRCP Part 2 Category: Neurology

MRCP2-3207

A 75 year old man is admitted to the medical assessment unit after a fall. According to his wife, he has been experiencing frequent falls (around 2-3 times a week) for the past 4 months, resulting in multiple hospital admissions where chest infections were thought to be the main cause of his deterioration. She also reports that he has been having difficulty swallowing, frequently chokes on his food, and has been exhibiting uncharacteristic aggression. Upon examination, the patient presents with an expressionless face, kyphosed posture, and mild bilateral tremors. There is cogwheeling in both upper limbs, but his legs appear normal. His gait appears parkinsonian in character, but he is stopped after only a few steps due to unsteadiness. During cranial nerve examination, he has difficulty following downward finger movements, but the rest of the examination is unremarkable. Based on these findings, what is the most likely underlying diagnosis?

MRCP2-3208

A 42 year old woman with a history of vitiligo and pernicious anemia presents with weakness primarily affecting her shoulder and hip muscles. The weakness varies throughout the day depending on her level of activity, with symptoms being most severe at the end of the day. Her family also notes a decrease in her voice volume during these times. On clinical examination, there is evidence of proximal muscle weakness after repeated testing. Electromyography reveals a decremental response in the amplitude of successive potentials. Serum testing for antibodies to the acetylcholine receptor (AChR) is negative, and a CT scan of the thorax is normal. What diagnostic tool would be most useful in establishing a diagnosis?

MRCP2-3209

A 38-year-old woman is referred to the TIA clinic for evaluation of recurrent left arm weakness. She reports experiencing repeated episodes of left-sided weakness accompanied by a unilateral throbbing headache, nausea, and sensitivity to light. During each episode, she notices weakness in her left arm. Her medical history includes a prior diagnosis of headaches, deep vein thrombosis during pregnancy, and hypothyroidism. She does not exhibit any neurological symptoms at present. Based on this information, what is the most probable diagnosis?

MRCP2-3201

A 55-year-old man was admitted to a tertiary referral center with severe right-sided weakness and a Glasgow Coma Score of 8. The onset of symptoms was estimated to be 6 hours prior to admission. The patient exhibited bilaterally up-going plantar responses and had no major co-morbidities. A CT scan of the brain revealed a significant area of infarction within the territory of the left middle cerebral artery, accompanied by massive cerebral edema and midline shift. What interventions may be beneficial for the patient during the acute phase?

MRCP2-3202

A 72-year-old patient is brought to the emergency department by ambulance after experiencing sudden right-sided weakness and dysphasia for the past five hours. A CT scan confirms an ischaemic stroke with no acute bleeding, but due to the delay in seeking medical attention, thrombolysis is not an option. The patient is admitted to the stroke ward and started on aspirin, but his reduced mobility puts him at risk for haemorrhagic transformation. What is the appropriate management strategy for his risk of venous thromboembolism?

MRCP2-3203

A 12-year-old boy is brought to the Emergency Department by his worried father. The patient has been complaining of widespread back pain for the past 2 days, which has only been partially relieved with regular painkillers. He has also experienced increased clumsiness and difficulty carrying heavier objects.
Over the last 24 hours, he has had a sudden onset of weakness in both his legs to the point where he is unable to lift them off the bed. He has no known medical conditions, but he has had several upper respiratory tract infections in the past few weeks. He is not taking any medications. The only significant medical history is that he had an episode of meningitis 2 years ago, from which he made a full recovery and was discharged from the hospital 1 month later.
During the examination, he is found to have normal sensation but reduced power in both his legs. The decrease in power is symmetrical. His tendon reflexes are absent, but his abdominal reflexes are normal. Examination of his cranial nerves confirms that he has weakness of eye closure, but the optic nerves’ fundoscopic appearance is normal. No other cranial nerve abnormalities are detected. He has mild shortness of breath, no fever, and is not tachycardic. Routine tests are performed in the emergency department, including a lumbar puncture (LP). The LP results show slightly elevated protein levels and normal cell counts. His serum white cell count is 10 × 109/l.
Which of the following investigations would be most beneficial for his immediate management?

MRCP2-3204

A 35-year-old teacher presents with a 2-month history of progressive difficulty with balance and coordination. She also reports experiencing numbness and tingling on the left side of her face and in her left hand. Two years ago, she had to take time off work due to weakness and stiffness in her legs.

During the examination, Ishihara colour-plate testing revealed deficits in the right eye. Her visual acuity is 6/6 on the left and 6/36 on the right. Eye movement testing showed nystagmus of the left eye when looking towards the left, with incomplete adduction of the right eye. Additionally, there is bilateral finger nose ataxia and impaired rapid alternating movements of the hands.

What would be the most appropriate initial investigation?

MRCP2-3196

A 42-year-old woman presents to the emergency department with confusion and fevers. She has no medical history and is not taking any regular medications.

Upon examination, her Glasgow coma scale is 13/15 (E3V4M5) and there are no localizing neurological signs. Cardiovascular, respiratory, and abdominal assessments are unremarkable. Her temperature is 38.8ºC.

An urgent MRI brain is scheduled, which reveals oedema of both temporal lobes.

A lumbar puncture is ordered.

What is the most likely set of results that will be found?

MRCP2-3197

A 16-year-old male is admitted to the hospital with worsening weakness in his limbs over the past 48 hours. He is experiencing difficulty walking and has become increasingly clumsy, dropping objects frequently. He also suffered a burn on his hand yesterday without realizing it until later. He reports feeling dizzy upon standing, but denies any chest pain or palpitations. He had a recent bout of vomiting and diarrhea four weeks ago, but is otherwise healthy and does not take any medications or use alcohol or tobacco.

During the examination, the patient’s blood pressure drops from 128/79 mmHg while lying down to 90/60 mmHg upon standing. His respiratory rate is 20 breaths per minute and his oxygen saturation is 97% on room air. His cardiovascular, respiratory, and abdominal exams are unremarkable. Neurological examination reveals symmetrical distal weakness in his lower limbs with relative proximal sparing and altered sensation to fine touch, vibration, and proprioception. Similar findings are observed in his upper limbs. The patient is suspected to have Guillain-Barre syndrome and is started on IV immunoglobulins after undergoing blood tests, CT head, and lumbar puncture. However, he begins to experience increasing shortness of breath and is referred to the intensive care unit for respiratory support.

What is the respiratory parameter used to determine the need for invasive ventilator support in this patient?

MRCP2-3198

A 65-year-old man with a history of type 2 diabetes and hypertension presents to the Emergency Department with weakness on the right side of his face and arm, which started five hours ago. Upon assessment, it is evident that he has had an acute stroke. What is the systolic blood pressure threshold that would require immediate treatment in this case?