A 35-year-old woman came to the clinic with a complaint of difficulty grasping objects for the past 10 months. She mentioned that the problem worsens during cold weather. She has no contact with her mother but recalls her having similar issues in her later years. During the physical examination, she displayed bilateral ptosis and facial muscle weakness. She also had trouble opening her eyes rapidly. Examination of her limbs revealed distal weakness in both hands, making it difficult for her to open and close them quickly. What is the most probable diagnosis?
MRCP2-3135
A 50-year-old sailor presents with recent weight loss of 2 kg. Upon further inquiry, he reports experiencing painful sensations in his legs at night, reduced sensation in his feet, and some issues with balanitis and urinary frequency. During the examination, he exhibits diminished proprioception at the toes, absent ankle reflexes, and a small painless ulceration on the ventral aspect of the big toe. His BMI is 28 kg/m2. Nerve conduction studies reveal reduced motor conduction velocities (75% of normal) in the legs, with small, poorly formed sensory nerve action potentials. Electromyography shows evidence of active denervation in the lower limbs with positive sharp waves and fibrillations. What is the most probable diagnosis?
MRCP2-3136
An 80-year-old man presented to the general medicine outpatient clinic with complaints of short term memory loss and reduced mobility. His wife reported a seven month history of poor concentration and described episodes in which her husband would be in a world of his own followed by periods where he could be completely normal. More recently he had had disturbing visual hallucinations. On examination, he had a marked dysarthria and perseveration, and bilateral rigidity and bradykinesia but no rest tremor. Investigations revealed normal blood tests. Based on these findings, what is the most likely diagnosis?
MRCP2-3137
A 32-year-old female equestrian had recently purchased new riding boots and a saddle for her horse. She had a long history of chronic low back pain and had been prescribed pain medication by her primary care physician. After a strenuous horseback riding session, during which her horse had performed well, she dismounted and experienced severe pain in her left leg, making it difficult to walk.
Upon examination, she exhibited a left foot drop, with the evertors and dorsiflexors of the left ankle measuring 2/5, while inversion of both ankles was 5/5. The straight leg-raising test was 80° on both sides, and tendon reflexes were normal. Pinprick sensation was reduced in the left foot.
What is the most likely diagnosis?
MRCP2-3138
A 35-year-old woman presents to the Emergency Department with a first episode of generalised tonic-clonic seizure. She is accompanied by her husband, who says she collapsed after coming home from work and suffered 3 minutes of generalised limb jerking, some foaming at the mouth and incontinence of urine. Further collateral history revealed that she had been vacant on a number of occasions for a few minutes. This also involved lip-smacking. She describes a feeling of déjà vu and a feeling of anxiety in her abdomen and chest area immediately prior to these episodes. On a number of these occasions, she seemed to lose track of where she was for some minutes. Past medical history includes migraines. There is no family history of note. Neurological examination in the clinic is unremarkable. Investigations:
Haemoglobin 145 g/l 135–175 g/l White cell count (WCC) 7.2 × 109/l 4–11 × 109/l Platelets 190 × 109/l 150–400 × 109/l Sodium (Na+) 142 mmol/l 135–145 mmol/l Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l Creatinine 90 µmol/l 50–120 µmol/l CT Head Normal What is the most likely diagnosis?
MRCP2-3139
An 80-year-old man presented with a history of memory fluctuations and agitation over the past year. He has also been experiencing visual hallucinations. His family became concerned and took him to see his GP, who prescribed haloperidol. However, the medication was recently discontinued as the patient’s condition worsened. Upon examination, the patient exhibited bilateral limb rigidity and bradykinesia, as well as a mild right-sided rest tremor. The rest of the neurological examination was unremarkable. What is the most likely diagnosis?
MRCP2-3140
An 88-year-old lady with a history of Parkinson’s disease and repeated admissions for aspiration pneumonias is admitted to the hospital with symptoms of diarrhoea, vomiting, malaise, stiffness, tremor, fever, and hallucinations. Her current medications include co-beneldopa, warfarin, amlodipine, amitriptyline, metformin, and lactulose. On examination, she is agitated, and a chest x-ray and abdominal examination are unremarkable. Blood tests reveal elevated creatinine, INR, and CRP levels, as well as positive ketones and trace blood in her urine. What would be the most appropriate next step in managing this patient’s condition?
MRCP2-3125
A 50-year-old man presents to his GP with a complaint of episodic vertigo that has been occurring for the past two weeks. He reports that the vertigo is particularly noticeable at night when he is trying to turn over in bed. He denies any history of nausea, vomiting, tinnitus, hearing problems, diplopia, or limb weakness. He recently had a cold and has been feeling under the weather in the last week, but otherwise has no other symptoms. He has a past medical history of epilepsy and takes regular carbamazepine. He is a non-smoker and drinks eight units of alcohol per week.
On examination, his vital signs are normal. The external auditory canal and tympanic membrane appear intact in both ears. Cranial nerve examination reveals asymmetric horizontal nystagmus with a rotational component, but ocular movements and pupillary responses are normal. The rest of the cranial nerves, including Weber and Rinne’s tests, are normal. Tone, power, reflexes, sensation, and coordination are normal in both the upper and lower limbs.
The Dix-Hallpike manoeuvre elicits a latent period to onset of nystagmus of 15 seconds, associated with vertigo and nausea. There is reversal of nystagmus on returning to an upright position. Fatiguing of symptoms and signs is observed on repeating the test. A contrast-enhanced CT scan of the brain is normal.
What is the likely cause of this patient’s vertigo?
MRCP2-3126
You are asked to evaluate a 36-year-old man who has been experiencing progressive limb weakness over the past 48 hours. The patient reports being an intravenous drug user and having a groin abscess drained recently. He also mentions having a stomach illness two weeks ago, but those symptoms have since resolved. During the physical examination, you observe flaccid weakness in all four limbs and absent reflexes in both lower limbs. The cranial nerves examination is unremarkable. What is the most likely diagnosis based on these findings?
MRCP2-3127
A 42-year-old Nigerian man presents with fatigue. He has been exhibiting strange behavior and psychotic symptoms for the past year and is currently being treated with risperidone. He was diagnosed with HIV-1 infection five years ago but has not been following up with treatment.
Upon physical examination, no abnormalities were found. His CD4 count is 20 × 106/l and HIV viral load is > 500,000 copies/ml. Antiretroviral therapy is initiated and the patient is discharged.
One month later, the patient returns with confusion. He is afebrile upon admission and disoriented in time and place but not in person. His CD4 count is now 50 × 106/l and HIV viral load is 503 copies/ml.
Further investigations reveal a hemoglobin level of 95 g/l, WCC of 4.8 × 109/l, neutrophils at 70%, lymphocytes at 20%, and platelets at 400 × 109/l. A CT scan of the brain shows multiple low-density lesions in the right hemisphere.
Cerebrospinal fluid analysis shows a white cell count of 150/ml, glucose level of 3.5 mmol/l, protein level of 0.6 mg/dl, and negative results for cryptococcal antigen, toxoplasmosis PCR, and India ink stain.
Four days later, the patient develops left-sided weakness. A magnetic resonance imaging scan with contrast shows diffuse enhancement of the lesions.