MRCP Part 2 Category: Neurology

MRCP2-3154

A 25-year-old woman presents to a general neurology clinic with complaints of increasing clumsiness with heavy objects over the past year. She reports difficulty washing her hair and completing household chores such as hanging up laundry. On neurological examination, her upper limb power is graded using the MRC system. Her left arm has 3/5 power for shoulder abduction and 4/5 power for shoulder adduction, while her right arm has 3/5 power for shoulder abduction and 4/5 power for shoulder adduction. Reflexes are normal except for an inability to elicit the supinator reflex on the right side. Sensation is intact. Cranial nerve examination reveals drooping of the eyelids and decreased facial expression. Fatigability tests are unremarkable. What is the most likely diagnosis?

MRCP2-3155

A 25-year-old man attends the Epilepsy Clinic. He has suffered tonic-clonic seizures for 7 years. After initial poor response, his epilepsy is now well-controlled on sodium valproate 1.5 g daily. He has been seizure-free for 3 years. His compliance with therapy is good.

From review of his case sheet, you note a family history of cerebrovascular disease with both grandparents suffering stroke.

At time of diagnosis, magnetic resonance imaging (MRI) brain showed no structural abnormality and interictal electroencephalogram (EEG) was unremarkable.

He is concerned over weight gain and hair loss that he attributes to his anticonvulsant therapy. He is considering stopping his sodium valproate.

What feature in his history predicts seizure recurrence upon discontinuation of therapy?

MRCP2-3156

A 40-year-old man presents to the Emergency department after being assaulted in the city centre. He sustained multiple knife wounds, including two in the left groin. On examination, there is reduced power of hip flexion and knee extension on the left, along with reduced sensation over the medial aspect of the left thigh. What is the probable cause of his symptoms?

Investigations revealed normal full blood count and biochemistry, with a glucose level of 5.6 mmol/L (3.0-6.0) and a prothrombin time of 11.5 s (11.5-15.5). A plain x-ray of the pelvis showed no evidence of fracture. The patient is a previously fit individual who smokes 10 cigarettes per day and drinks approximately 20 units of alcohol per week.

MRCP2-3141

A 35-year-old woman is brought to the Intensive Care Unit after a serious head injury. She meets the requirements for brainstem death and has a registered organ donor card. However, her family is opposed to organ donation.

What is the best course of action in this situation?

MRCP2-3142

A 55-year-old construction worker presents to the hospital after collapsing on the job. He is a smoker of 15 cigarettes per day but has no other medical history. Upon awakening at the construction site, he experienced slurred speech, dizziness, and temporary symptoms on the left side of his body. These symptoms had resolved by the time he arrived at the Emergency Department. Imaging revealed a proximal stenosis of the right subclavian and carotid arteries. EEG results were negative for spike activity. What is the most likely diagnosis based on this clinical presentation?

MRCP2-3143

A 25-year-old woman was brought to the Emergency Room by her sister as she had been exhibiting aggressive behavior and was difficult to handle, both at work and home, for the past few months. She had a habit of touching other people and would occasionally make strange noises and shout obscenities without any reason.
During the examination, she repeatedly blinked her eyes and had involuntary twitches. Other than that, the neurological examination was normal. There were no significant findings on the general physical examination, with a regular pulse of 80 bpm and blood pressure of 120/80 mmHg.
What is the most probable diagnosis?

MRCP2-3144

A 68-year-old woman comes to the clinic complaining of gait ataxia, dysarthria, and dysphagia that have been present for the past 2 years. Upon examination, the patient exhibits downbeating nystagmus and slurred speech. Both upper limbs show past pointing, and the patient has a wide-based ataxic gait. Reflexes and sensation are normal, and there is no wasting or fasciculations. The plantar response is flexor bilaterally. What is the most likely diagnosis?

MRCP2-3131

A 32-year-old intravenous drug user presents with a 3-day history of double vision, difficulty swallowing, slurred speech, and overall weakness. During the examination, the patient displays numerous skin lesions and an infected wound on their right thigh. They exhibit ophthalmoplegia with limited gaze in all directions, bilateral facial nerve weakness, and dysphonia. The patient’s limb examination reveals global flaccid weakness, which is worse proximally. Reflexes are diminished. The general medical examination is unremarkable except for shallow breathing.

Spirometry results are as follows:
– FVC: 50% of predicted
– FEV1: 50% of predicted
– FEV1/FVC: 0.84
– TLCO: low
– KCO: high

Cerebrospinal fluid (CSF) examination shows:
– Glucose: 3.5 mmol/l (serum 6.0)
– Protein: 0.45 g/l (normal 0.3-0.5)
– White cell count (WCC): 1 cell/mm3 (normal < 5)
– Red cell count (RCC): none seen
– Gram stain: negative
– Culture and PCR: pending

What is the most likely causative agent?

MRCP2-3132

A 48-year-old man presents with bilateral facial weakness and diplopia that has been worsening over the past five days. He is unable to fully close his eyes, which are becoming red and dry. He denies any recent infections or headaches and has not experienced any weakness or numbness in his limbs or difficulty breathing. His medical history includes left uveitis, which was treated with topical steroids when he was 18 years old. He is a non-smoker, drinks 24 units of alcohol per week, and is not taking any regular medication. On examination, there is a painful circular nodular lesion over his left shin, and he has marked bilateral lower motor neuron facial weakness with an additional right VI nerve palsy. A CT scan of the brain is normal, but a lumbar puncture reveals an opening pressure of 16 cmH2O, CSF protein of 1.5 g/L (0.15-0.45), CSF white cell count of 125 cells per ml (≤5), CSF white cell differential of 90% lymphocytes, CSF red cell count of 4 cells per ml (≤5), CSF glucose of 3.5 mmol/L (3.3-4.4), and positive CSF oligoclonal bands. What is the most likely diagnosis for this patient?

MRCP2-3133

A 35-year-old woman presents to the Emergency Department with complaints of severe headache and sensitivity to light. She has also vomited once. On examination, she has a fever of 38.5 °C and enlarged cervical lymph nodes. Chest auscultation is clear. A CT scan of her head is performed, which rules out any mass lesion and indicates that lumbar puncture can be safely performed. The CSF results are as follows: clear appearance, predominantly mononuclear cells, white cell count of 4.2 per mm3, glucose level of 3.8 mmol/l, plasma glucose level of 5.2 mmol/l, and protein level of 0.51 g/l. What is the most likely diagnosis in this case?