MRCP Part 2 Category: Neurology

MRCP2-3128

A 12-year-old boy is brought by his father to the clinic for evaluation of his neurological status. He has been experiencing a decline in academic performance for the past 4 months, and has been recently observed by his teacher to have outbursts of anger in the classroom.

His father is concerned that in the early morning his son experiences sudden contractions of his shoulder muscles and complains of blurry vision. This has been happening for the past 2 weeks. On the morning of his visit, he had a seizure followed by loss of consciousness. In his early childhood, he had a rash illness from which he recovered without any complications.

During the examination, the boy is lethargic and uncooperative. Cranial nerves appear normal. He experiences sudden contractions involving all four limbs. Tendon reflexes are brisk with bilateral Babinski’s sign. He has a wide-based gait and is unable to walk in a straight line. Blood pressure is noted at 110/75 mmHg, with pulse 90 bpm and regular. General physical review is unremarkable, as are routine blood tests and a chest X-ray.

What is the most likely diagnosis?

MRCP2-3129

A 25-year-old Japanese woman was brought to the Emergency Room on a stretcher as she was found lying on the floor of her apartment unable to move by her roommate. She had participated in a 5K race at a local park, the day before and had eaten a full chocolate cake before going to bed. She got up around 4 am to get a glass of water and noticed weakness in her limbs. She could hardly hold the glass and finally fell on the kitchen floor. Over the past few weeks, she has suffered from increasing heart palpitations and stress related to her upcoming exams.

Upon examination, she was of average build and anxious. She gave a clear account of the progression of her illness. Pulse was 110/min and irregularly irregular. Blood pressure was 130/90 mmHg. Cranial nerves were normal. Neck muscle power was 4/5. Shoulder girdle, truncal and pelvic girdle muscles 3/5. Tendon reflexes were decreased and plantar were absent. Sensation was intact.

What is the most probable diagnosis?

MRCP2-3130

A 35-year-old man presented to the emergency department with complaints of intense neck pain after shooting at a rifle range. He subsequently experienced vertigo, nausea, and vomiting. A few hours later, he was discovered collapsed at home and brought to the hospital by ambulance. On arrival, his Glasgow Coma Scale (GCS) score was 10 out of 15. What is the most probable reason for his symptoms?

MRCP2-3116

A 45-year-old office worker presented with a 9-month history of gradual weakness in their left hand and a 4-month history of similar weakness in their right hand. They had no significant medical history. On examination, there were fasciculations in both biceps muscles with increased tone in both arms, weakness of intrinsic hand muscles bilaterally, and brisk upper limb reflexes. Coordination and sensory examinations were unremarkable. What is the most probable diagnosis?

MRCP2-3117

A 42-year-old man is brought to the Emergency Department after a fall from a ladder while doing home repairs. He has no significant medical history.
Upon examination, he is on a backboard with his cervical spine immobilized. His initial exam shows a slight drooping of the right eyelid with a constricted pupil. Examination of his mouth reveals a deviation of the tongue to the right. There are no other notable neurological findings. He reports a change in taste sensation.
What is the most probable cause of these symptoms?

MRCP2-3118

A 25-year-old female patient visited her GP complaining of double vision and painful right eye that had been persisting for six weeks. She had experienced similar visual problems with her left eye three years ago, which lasted for several days. The patient had no past medical history, was not taking any regular medication, and had a family history of neurological disease as her mother had died of a similar condition. She smoked 10 cigarettes per day and consumed 21 units of alcohol per week.

During the examination, the patient appeared alert and orientated. The right pupil was sluggish in reacting to light, and visual acuity was 6/9 in the right eye and 6/6 in the left. There was no evidence of proptosis or conjunctival injection. The patient complained of diplopia on looking to the left, and there was oculoparesis of the adduction of the right eye with nystagmus of the abducting eye. The rest of the cranial nerves were normal. Peripheral nervous system examination revealed bilateral past-pointing, which was worse on the right. The patient had a mildly ataxic gait, but Romberg’s test was negative. Tone, power, reflexes, and sensation appeared normal.

The investigation results showed normal levels of haemoglobin, mean cell volume, white cell count, platelets, serum sodium, serum potassium, serum urea, serum creatinine, serum C-reactive protein, fasting plasma glucose, serum folate, and plasma TSH. The patient’s serum B12 level was within the normal range, and plasma T4 and T3 levels were slightly low. A lumbar puncture was performed, and the CSF analysis showed a positive oligoclonal band and no other abnormalities.

What is the most likely diagnosis for this 25-year-old female patient based on her history and clinical findings?

MRCP2-3119

A 35-year-old carpenter complains of sudden-onset back pain. He was working on a project when he realised he couldn’t stand up. Upon examination, he has bilateral leg weakness with lower limb hyporeflexia. He has pinprick sensory loss up to the level of the navel. Vibration sense is mildly impaired at the ankles and clearly present at the knee. He is experiencing urinary retention. The patient has a history of hypertension and takes ramipril 10 mg daily. What is the most likely diagnosis?

MRCP2-3120

A 65-year-old retired builder presented to his GP with a progressive history of stiffness and weakness affecting both legs. He had recently started dragging his right leg and had noticed some urinary incontinence. His symptoms had come on gradually over a period of four months.

There was no history of trauma; however he had had a bout of gastroenteritis in the last few weeks, which he had attributed to eating a take-away curry. His past medical history included rheumatoid arthritis and tension headaches, which had been more frequent of late, and borderline hypertension. He was a smoker of 20 cigarettes per day and drank 20 units of alcohol per week.

On examination he was alert and orientated. His blood pressure was 142/89 mmHg, pulse 89/min and temperature was 36.7°C. On examination of cranial nerves, no abnormalities were found. On examination of the peripheral nervous system, upper limb was entirely normal, however on examination of the lower limb there was marked spasticity, hyperreflexia with extensor plantar responses. Power was grade 4/5 on the left and 3/5 on the right with a pyramidal pattern of weakness. There did appear to be some sensory neglect of the right lower limb and diminished vibration and light touch on the left lower limb. No sensory level could be detected. There was no cerebellar dysfunction. Chest and abdominal examination was normal.

He was investigated with an MRI thoracic spine, which was entirely normal, and lumbar puncture.

Lumbar puncture showed:
Opening pressure 13 cm H2O (5-18)
CSF protein 0.6 g/L (0.15-0.45)
CSF white cell count 20 per ml (> 5)
CSF red cell count 4 per ml (>5)
CSF glucose 3.4 mmol/L (3.3-4.4)
CSF oligoclonal bands Present –
Serum oligoclonal bands Present –

What is the likely diagnosis in this 65-year-old patient based on the history and findings?

MRCP2-3121

A 25-year old woman, who has been out of work since dropping out of college early, arrived at the Emergency Department with a sudden onset of left-sided hemiparesis. Her father mentioned that she had been hospitalized for chest pain 4 years ago, but he did not have any further information about the admission. She occasionally smokes cigarettes when she can afford them.

During the examination, she had a flushed face and livedo reticularis on her thighs. She was 1.7 m tall and had scoliosis. Her blood pressure and heart sounds were normal. Her Mini-mental scale score was 26/30. She had a slight left-sided facial palsy and pyramidal weakness in her left limbs. Her speech and sensory system were normal.

What is the most probable underlying diagnosis?

MRCP2-3122

A 32-year-old man presents to the Emergency department with a three-day history of paraesthesia in his feet and hands. He has also noticed weakness in his thighs, particularly when walking down stairs, and weakness affecting his shoulders. Prior to this, he had been well, except for a mild case of gastroenteritis after eating Chinese food. On examination, he appears anxious, but cranial nerve examination and fundoscopy are normal. Upper limb examination reveals reduced tone and absent reflexes bilaterally at both wrists. Lower limb examination shows 2/5 power, absent reflexes, and reduced sensation affecting both feet. A lumbar puncture is performed, yielding the following results: opening pressure 14 cmH2O (5-18), CSF protein 0.40 g/L (0.15-0.45), CSF white cell count 4 cells per ml (<5 cells), CSF red cell count 2 cells per ml (<5 cells), and negative CSF oligoclonal bands. What is the diagnosis for this patient?