MRCP Part 2 Category: Neurology

MRCP2-3123

A 54-year-old woman presents to the Emergency department with severe back pain and subsequent weakness and paraesthesia affecting both legs. She is unable to urinate and her leg weakness worsens. She recently returned from a holiday in Tenerife and has a medical history of diabetes, hypertension, and hypercholesterolaemia. She drinks 15 units of alcohol per week but does not smoke. On examination, she appears distressed with a palpable bladder and neurological deficits in the lower limbs. A lumbar puncture reveals normal CSF results. What is the most likely diagnosis?

MRCP2-3124

A 42-year-old man had surgery to remove a tumor from his right lung three years ago. He received postoperative radiation therapy of 5000 cGy. His primary care physician has referred him for assessment of a painful right arm with weakness.
During the examination at the clinic, the patient appears alert but apprehensive. The right palpebral fissure is slightly smaller than the left, but eye movements are normal. The right pupil is smaller than the left. Swallowing and speech are normal, as is facial expression. The small muscles of the right hand are atrophied and weak, with clawing affecting the right ring and little fingers. There is decreased sensitivity to pinprick on the ulnar border of the right hand and forearm.
What is the most probable underlying diagnosis?

MRCP2-3109

A 65-year old man presents to the clinic with a 2-week history of tingling in his hands and feet. He has also noticed that his legs feel weaker than usual. He has a history of high blood pressure and no other medical conditions. His vital signs are stable, but he appears sweaty and has a rapid heart rate. On examination, he has bilateral facial weakness and grade 4 weakness in his upper and lower limbs. His reflexes are present but require reinforcement. He has reduced sensation in his toes, ankles, and fingers. Which investigation is most likely to aid in the suspected diagnosis?

MRCP2-3110

A 65-year-old man presents with a 12-month history of forgetfulness and paroxysmal drowsiness. Upon examination by his GP, bilateral bradykinesia and rigidity in the upper limbs were found, and he was started on L-dopa. However, six weeks later, he developed formed visual hallucinations that persisted despite stopping the medication. The GP then prescribed a small dose of haloperidol (5 mg), but the patient experienced severe vomiting and drowsiness, which resolved upon discontinuing the medication. The patient has mild bradykinesias and rigidity in the upper limbs with rest tremor of the left arm, and his mini mental examination score is 20/30. The remainder of the examination is normal.

Investigations show normal results for CT brain and EEG, as well as for haemoglobin, white cell count, platelets, serum sodium, serum potassium, serum urea, serum creatinine, serum albumin, serum total bilirubin, serum aspartate aminotransferase, serum alkaline phosphatase, plasma glucose, free T4, free T3, and plasma TSH. However, the serum vitamin B12 level is low at 228 ng/L (160-760), and VDRL is negative.

What is the most likely diagnosis?

MRCP2-3111

A 44-year-old woman with a relapsing and remitting multiple sclerosis history presents for follow-up at the clinic. She has been stable for the last 6 months and is currently on oral fingolimod treatment. During the neurological examination, there is noticeable coordination impairment, particularly on the left side, but no other significant indications.
What accurately describes the mechanism of action of fingolimod?

MRCP2-3112

A 19-year-old man presents with painless visual loss in his left eye over the course of 24 hours. He had previously lost vision in his right eye over the past two weeks, with no improvement in the following two months. He denies any other symptoms and has no significant medical history. He smokes 10 cigarettes per day and drinks 20 units of alcohol per week. Physical examination reveals bilateral optic atrophy and impaired color vision in both eyes. All other neurological exams are normal. Various tests, including a full blood count, liver function tests, and MRI brain and orbits, all come back normal. What is the most likely diagnosis?

MRCP2-3113

A 28-year-old female presents to the Emergency department with complaints of headaches and diplopia. She reports experiencing a generalised and throbbing headache with associated nausea since the morning. Over the last two hours, she has noticed pain and double vision when looking to the right, and her left eyelid has started to droop. She denies any changes in facial sensation or weakness in her arms or legs. Her medical history includes migraines, for which she occasionally takes Imigran. She is a smoker and drinks alcohol regularly.
On examination, she is alert and oriented with mild nuchal rigidity. Fundoscopy is normal, but she has photophobia. Cranial nerve examination reveals a left oculomotor nerve palsy with left-sided ptosis and mydriasis. There is no evidence of chemosis or proptosis, and the rest of the cranial nerves and visual fields appear normal. Peripheral nervous system examination is unremarkable.
Laboratory investigations show a slightly low serum potassium level and a mildly elevated C-reactive protein level. Given the clinical presentation, which investigation is most likely to lead to a definitive diagnosis?

MRCP2-3114

A 60-year-old woman presents to a neurologist with worsening morning headaches that are throbbing and accompanied by nausea. She reports that the headaches are positional and worsen when lying down. Additionally, she has noticed a decline in her sense of smell and has difficulty seeing out of her right eye. She denies pain or diplopia but has been experiencing left-sided clumsiness. She has a medical history significant for hypertension, hypercholesterolemia, and ischemic heart disease and takes aspirin, ramipril, and simvastatin. She smokes 10 cigarettes per day and drinks four units of alcohol per week. On examination, she has bilateral non-tender pulsatile temporal arteries and a sluggish direct pupillary reflex on the right with a relative afferent pupillary defect. Fundoscopy reveals right optic atrophy and mild swelling of the left optic disc with peripapillary hemorrhages. Visual field testing shows a central scotoma on the right and restriction of visual fields on the left. The rest of the cranial nerves are normal, and examination of the peripheral nervous system is unremarkable. Laboratory investigations are within normal limits except for a slightly elevated white cell count and a low ESR. What is the most likely diagnosis for this patient’s symptoms?

MRCP2-3115

A 58-year-old man presented to his GP with complaints of weight loss and weakness that he had been experiencing for some time. He mentioned that his clothes no longer fit him properly. He had noticed progressive weakness in both his legs, along with wasting of the thighs and thinning around the ankles. Additionally, he had been experiencing slurring of speech and nasal regurgitation while eating. His medical history included chronic bronchitis, prostatic hypertrophy, and osteoarthritis affecting the cervical and lumbar spine. He was currently taking a salbutamol and beclasone inhaler.

Upon examination, the patient appears cachectic with muscle wasting in his arms and legs. Chest and abdominal examination appeared normal. Cranial nerve examination revealed a pseudobulbar palsy, decreased palatal elevation, and wasting of the tongue with fasciculations. There was also a brisk jaw jerk. Upper limb examination showed normal tone, but asymmetrical wasting of the forearms and dorsal interossei bilaterally. There was also asymmetrical weakness of hand grip (right greater than left) and weakness of wrist flexion/extension. Reflexes appeared pathologically brisk, and there were positive Hoffman signs bilaterally. Lower limb examination revealed bilaterally increased tone with fasciculations of the thighs. There was marked weakness of dorsiflexion and plantar flexion of the left foot and bilateral weakness of hip flexion that was more pronounced on the left than the right. Sensory examination and cerebellar function were normal.

Blood tests showed normal liver function, sodium, potassium, urea, creatinine, and prostate specific antigen levels. The patient’s calcium level was slightly elevated. MR brain and chest x-ray were normal, but MRI spine showed degenerative disc disease affecting the lumbar and cervical spine. Electromyography and nerve conduction studies revealed spontaneous fasciculation potentials affecting all four limbs.

What is the most likely cause of this patient’s symptoms based on his history and clinical findings?

MRCP2-3102

A 65-year-old retired librarian presented to her general practitioner with a gradual onset of unsteadiness of gait, resulting in her having to hold onto furniture to move around her house. She also experienced difficulty in reading her books and frequently lost her place while scanning the text. Her husband noticed a slowing of performing simple tasks such as making a meal, washing, or eating, and now needed to accompany her to the shops and help in most tasks because of her unsteadiness.

Her medical history included hypertension, hypothyroidism, and osteoarthritis. She was taking bendroflumethiazide 2.5 mg daily and thyroxine 75 mcg daily. On examination, her blood pressure was 102/65 mmHg (lying) and 97/55 mmHg (standing). Her pulse was 67/minute and regular, and she had marked dysarthria. On examination of eye movements, there was normal smooth pursuit, but slow vertical saccades and evidence of square wave jerks. She also had slow spastic tongue movements. On examination of the upper limb, there was marked neck rigidity with retrocollis and evidence of symmetrically increased tone and bradykinesia. On examination of the lower limb, there was symmetrically increased tone, bradykinesia, and gait instability.

Investigations revealed:
– Serum sodium 135 mmol/L (137 – 144)
– Serum potassium 3.8 mmol/L (3.5 – 4.9)
– Serum urea 5.4 mmol/L (2.5 – 7.5)
– Serum creatinine 100 mol/L (60 – 110)
– Serum thyroxine 60 nmol/L (58 – 178)
– Serum thyroid stimulating hormone 6.5 mU/L (0.4 – 5)

An MRI scan of her brain showed midbrain atrophy. What is the most likely cause of this patient’s symptoms and signs?