MRCP Part 2 Category: Neurology

MRCP2-3159

A 35-year-old woman presents to the neurology clinic with a history of intermittent headaches for the past 6 months. The headaches predominantly affect the left side of her head and are accompanied by paraesthesia in her left hand, as well as occasional nausea and vomiting. The patient reports that her symptoms usually resolve after 4-6 hours. She has no significant medical history and is not taking any regular medications or has any allergies.

Upon examination, the patient’s vital signs are within normal limits. There is no sensory or coordination disturbance, and all four limbs have equal power. The cranial nerve examination is unremarkable.

What would be the most appropriate course of action for the long-term management of this patient?

MRCP2-3145

A 78-year-old man presents to the neurology clinic with complaints of slowness. He is accompanied by his wife who reports that he has been progressively slowing down in his movements and facial expressions. The symptoms have worsened rapidly since he experienced dizziness a few weeks ago. The patient has a medical history of type two diabetes, hypertension, high cholesterol, and a previous hemicolectomy for diverticulitis. He is currently taking ramipril, atorvastatin, paracetamol, amlodipine, metformin, prochlorperazine, and gliclazide. On examination, he exhibits a coarse bilateral tremor at rest, rigidity in both arms, and a slow gait. What is the most likely diagnosis?

MRCP2-3146

A 32-year-old caucasian woman is 28 weeks pregnant. She has been epileptic since the age of 7 and takes lamotrigine, which she has continued throughout the pregnancy. She has not had a seizure for 2 years. What factors should be taken into account for pregnant patients on lamotrigine?

MRCP2-3147

A 40-year-old man visits the first fit clinic after experiencing a witnessed tonic clonic seizure that lasted a few minutes. Following an MRI and EEG, both of which were reported as normal, he was not prescribed any treatment and was instructed not to drive upon discharge from the hospital. Assuming he remains seizure-free, when will he be permitted to resume driving?

MRCP2-3148

A 30-year-old man comes to the Emergency Department following a single tonic-clonic seizure that lasted for 4 minutes, witnessed by his friend. A CT scan of his brain shows no abnormalities, and his electrolytes, calcium, and magnesium levels are normal. He undergoes an EEG and MRI brain scan as an outpatient, both of which come back normal. He chooses not to begin any anti-epileptic medication. When will he be able to drive again?

MRCP2-3149

A 32-year-old woman who recently traveled to Brazil presents to the Emergency Department with fever, headache, and muscle pain. She has a history of insulin-dependent diabetes mellitus. She is admitted due to worsening headache and back pain and becomes increasingly drowsy while waiting in the medical receiving unit. On examination, she has flaccid paralysis and decreased tendon reflexes. A CT scan of the brain is normal. Cerebrospinal fluid examination shows a protein level of 1.2 g/l (normal < 0.45 g/l), glucose level of 3.8 mmol/l (normal 2.5-3.9 mmol/l), and a white cell count of 200/mm3 (mostly lymphocytes) (normal < 5/mm3). Laboratory investigations reveal a hemoglobin level of 140 g/l (normal 135-175 g/l), platelet count of 400 x 109/l (normal 150-400 x 109/l), white cell count of 11.0 x 109/l (normal 4.0-11.0 x 109/l), sodium level of 138 mmol/l (normal 135-145 mmol/l), potassium level of 4.5 mmol/l (normal 3.5-5.0 mmol/l), creatinine level of 110 µmol/l (normal 50-120 µmol/l), and a urea level of 6.5 mmol/l (normal 2.5-6.5 mmol/l). What is the most likely infectious process?

MRCP2-3150

A 35-year-old construction worker presented to the Emergency department with symptoms of vertigo, dysarthria, ataxia, nausea, and vomiting. He reported experiencing severe occipital pain for the past five hours, which began while he was working on a construction site. He denied any hearing or visual impairments and had no past medical history or prescribed medication use. He was a smoker of 20 cigarettes per day and drank 20 units of alcohol per week, but denied any illicit drug abuse. There was a family history of stroke, and his mother had died of subarachnoid hemorrhage at the age of 43.

Upon examination, the patient was pale and vomiting and complained of severe occipital head pain. His pulse was 80/min and regular, blood pressure was 120/80 mmHg, and temperature was 36.5°C. Heart sounds were normal, and fundoscopy showed no abnormalities. However, his pupils appeared sluggishly reactive to light. During cranial nerve examination, he exhibited gaze-evoked nystagmus towards the right and had a marked dysarthria. On peripheral nervous system examination, there was an intention tremor of the right arm. Tone, power, reflexes, and sensation were all normal. On lower limb examination, he walked with an ataxic gait and appeared to be veering towards the right.

Based on these findings, what is the likely diagnosis for this 35-year-old construction worker?

MRCP2-3151

A 19-year-old female presents to the clinic with complaints of speech difficulties and slowing of movements. Upon examination, bilateral rigidity, akinesia with loss of arm swing, and bradykinesia are observed. Which medication could be responsible for inducing this disorder?

MRCP2-3152

A 31-year-old man presents with left eyelid drooping and drooling from the side of his mouth. This started three weeks ago and he has also been experiencing fatigue. He denies having a fever and reports no weakness in any other parts of his body. He has a dry cough that he attributes to hay fever. His left ear has reduced hearing and has been painful.

Additionally, he has a faded red rash on his legs. He has no past medical history, has not traveled abroad, and is sexually active with a single male partner. He had shingles three months ago.

During the examination, he has a clear left-sided facial droop with normal sensation and no sparing of the forehead. He has normal power in all four limbs with no sensory loss. There is a faint red circle on the right leg surrounding a central red area within. Scattered crepitations are present in the lungs. He has pain in his left ear with an effusion behind the tympanic membrane.

Hb 156 g/l Na+ 135 mmol/l
Platelets 345 * 109/l K+ 4.5 mmol/l
WBC 12 * 109/l Urea 4.2 mmol/l
Neuts 9 * 109/l Creatinine 94 µmol/l
Lymphs 1 * 109/l CRP 34 mg/l
Eosin 0.2 * 109/l
Corrected Calcium 2.2mmol/l

ECG sinus, PR interval 202ms
Chest x-ray no abnormalities seen

What is the likely diagnosis?

MRCP2-3153

A 40-year-old man presents with weakness in raising his arms and some drooping of the eyelids. He also has pronounced shoulder blades. He mentions that his symptoms are mild and he may not have noticed them if his father had not experienced similar symptoms that have worsened over time. The patient has no significant medical history and is not taking any regular medications. Upon examination, there is mild evidence of scapula winging, proximal weakness in both upper limbs, ptosis, and difficulty whistling. However, there is normal power in his lower limbs, and his reflexes and sensation are intact throughout.

The patient’s creatine kinase level is 220 units/L. A muscle biopsy has been taken but is still pending. What is the most likely diagnosis?