MRCP Part 2 Category: Neurology

MRCP2-3199

A 57-year-old male presents to the Emergency Department with a sudden onset of weakness in his right arm and leg that started while he was at work. He reports some improvement in strength but still feels definite weakness. His medical history includes hypertension, hypercholesterolaemia, and a previous myocardial infarction. He is currently taking lisinopril 10mg OD, atorvastatin 40 mg OD, and aspirin 81mg OD. On examination, he has a right-sided hemiplegic gait and decreased power (3/5) in all muscles of the right upper and lower limbs, with decreased tone and absent deep reflexes. Sensation and coordination testing are unremarkable. His blood pressure is 160/90 mmHg, heart rate 80 bpm, respiratory rate 18/min, temperature 37.0 C, and oxygen saturations 98% on air. His ECG shows sinus rhythm with left ventricular hypertrophy. CT head scan shows no evidence of intracranial haemorrhage, mass shift, or space-occupying lesions. What is the next best management step?

MRCP2-3200

A 59-year-old man presents to the neurology clinic with a history of increasing bilateral hand weakness and clumsiness over several months, with the right hand being worse than the left. He reports difficulty with writing, fine manipulation, and poor hand grip. He denies any sensory disturbance or neck problems but has recently developed weakness in his right knee. His medical history includes hypertension and hypercholesterolemia, and he takes bendroflumethiazide and simvastatin regularly. He smokes 20 cigarettes per day and drinks 10 units of alcohol per week. On examination, there is bilateral hand and forearm wasting with absent clawing or fasciculations, and reduced muscle bulk of the proximal musculature. Shoulder abduction/adduction is 3/5, and there is marked distal weakness affecting wrist and finger flexors of 2/5. Sensation is intact. Investigations reveal a fasting plasma glucose of 8.5 mmol/L, and a lumbar puncture shows an opening pressure of 10 cmH2O, CSF protein of 0.35 g/L, and CSF white cell count of 4 cells per ml. Which investigation is most likely to confirm the diagnosis?

MRCP2-3189

A 50-year-old man presents with complaints of lower limb numbness and weakness, along with recent urinary incontinence and blurred vision. On examination, he has bilateral lower limb weakness (grade 3+/5) with spastic tone and exaggerated reflexes. Sensory level is at T10. MRI of the spine shows a hyper intense lesion spanning from T7-T12. His medical history includes well-controlled asthma with salbutamol inhaler. Laboratory investigations reveal normal electrolytes, renal function, and urine analysis, with negative ANA. CRP and ESR are mildly elevated. Which investigation would be most helpful in reaching a diagnosis?

MRCP2-3190

A 53-year-old man presents to the Neurology clinic with a 2-month history of nocturnal headaches and difficulty walking. Upon examination, he displays an ataxic gait and impaired coordination affecting his left arm and leg. Blood tests reveal normal results, except for a slightly elevated CRP level. A CT brain scan is performed, which shows a well-defined, low attenuation region in the posterior fossa with an enhancing nodule on the wall. What is the probable underlying lesion causing these symptoms?

MRCP2-3191

A 32-year-old woman presents to the emergency department with abdominal pain. She has a history of mild depression and hay fever, and takes paroxetine and PRN loratadine. She reports experiencing generalised colicky abdominal pain and has vomited once in the department. On examination, her blood pressure is 155/86 mmHg, heart rate is 95 bpm, and temperature is 37.9ºC. A digital rectal examination reveals hard stool in the rectum. Investigations reveal Hb 131 g/l, platelets 362 * 109/l, WBC 7.3 * 109/l, Na+ 121 mmol/l, K+ 3.3 mmol/l, urea 6.2 mmol/l, creatinine 87 µmol/l, and a urine dipstick showing protein ++ and leucocytes ++. What is the most likely diagnosis?

MRCP2-3192

A 75-year-old man arrives at the emergency department by ambulance after experiencing sudden speech difficulty, numbness, and weakness for the past eight hours. Despite his symptoms, he was hesitant to seek medical attention due to concerns about the ongoing coronavirus pandemic. The patient has a medical history of hypertension, hypercholesterolemia, and ischemic heart disease, and is currently taking aspirin, atorvastatin, bisoprolol, and amlodipine. He is a non-smoker and drinks only minimal amounts of alcohol. He typically lives independently with his wife.

Upon examination, the patient exhibits expressive dysphasia and right-sided hemisensory loss affecting his face, arm, and leg. There is also evidence of facial weakness, and his right upper limb has a power of 3/5 while his right lower limb has a power of 4/5. Chest auscultation is normal, heart sounds are audible with no murmurs, and his pulse is irregular. There are no carotid bruits. Urinalysis is unremarkable, and bedside testing reveals a glucose level of 7.1 mmol/L. An ECG shows atrial fibrillation, and an urgent CT angiography reveals occlusion of the proximal anterior circulation. An hour later, a diffusion-weighted MRI shows limited core infarct volume.

What is the most appropriate course of action for this patient?

MRCP2-3193

A 67-year-old woman was admitted to the hospital for surgery to remove a breast carcinoma. The day after her admission, she had a generalised tonic-clonic seizure on the ward. Despite feeling relatively well before the seizure, she had a history of heavy alcohol abuse and had drunk heavily prior to admission. She was treated for alcohol withdrawal with thiamine and chlordiazepoxide. The following day, she underwent surgery, and due to a stormy postoperative period, she was ventilated and admitted to intensive care. After three days, she was steadily weaned off the ventilator and sedation, but was thought to be in a coma with no limb response to pain.

She had a past medical history of hypertension treated with bendroflumethiazide 2.5 mg/day, but no other known medical problems. On examination, her vital signs were all normal. On neurological assessment, there was eye opening on vocal commands. There was some bilateral blepharospasm with normal vertical doll eye movements, but impaired horizontal doll’s eye. The pupillary responses were normal and symmetrical. Facial grimace was symmetrical. Upper limb examination revealed normal tone and reflexes, and lower limb tone was normal with depressed knee and ankle jerks and bilateral flexor plantar responses.

Investigations revealed a low haemoglobin level, normal white cell count and platelets, and a slightly elevated mean cell volume. Her serum electrolytes and glucose were within normal limits, and a CT scan of her brain without contrast was normal. A lumbar puncture was performed and yielded normal opening pressure, slightly elevated protein levels, and a few white and red blood cells.

What is the most likely cause of this patient’s clinical condition?

MRCP2-3178

A 42-year-old woman presented to the hospital with a severe headache on the right side and loss of vision that had been going on for two days. She had a history of hypertension and was taking bendroflumethiazide. Her family had a history of thyroid problems, and she had experienced intermittent headaches in the past, although they were not regular. On examination, she was agitated and distressed, with a temperature of 37.5°C, a pulse of 110 beats per minute, and a blood pressure of 145/95 mmHg. The right eye showed chemosis and proptosis, with upward and downward gaze paralysis and preserved lateral gaze. The right pupil was dilated and unresponsive to light, while the left eye was normal. Bilateral papilloedema was observed during fundoscopy. What is the most likely diagnosis?

MRCP2-3194

The husband of a 49-year-old man with Parkinson’s disease has been spending excessive amounts of money on gambling, causing concern for his wife. Despite having a history of gambling, the amount he is now spending is significantly higher and he appears to be concealing his actions. He was diagnosed with Parkinson’s disease 7 years ago and is currently stable in terms of motor symptoms, with only mild mood fluctuations. He is taking co-careldopa and ropinirole. What is the most probable cause of his gambling behavior?

MRCP2-3179

An 85-year-old man presents to his GP with sudden uncontrollable flinging movements of his right arm and leg. He had no prior history of such movements. The irregular movements involve the proximal limb muscles and occur several times a minute, leading to falls. The patient has a medical history of hypertension and ischaemic heart disease and takes regular ramipril and aspirin. He is a smoker and does not drink alcohol. On examination, the patient is alert and oriented, but the flinging movements make examination difficult. General examination reveals a blood pressure of 140/90 mmHg and a pulse of 78/min. Investigations reveal normal tone, power, and reflexes, and no cranial nerve abnormalities. Based on the history and findings, where is the probable location of the lesion?