MRCP Part 2 Category: Neurology

MRCP2-3103

A 35-year-old woman presents to the Emergency department with a four-day history of worsening weakness affecting both legs. She reports difficulty walking downstairs and rising from a chair, as well as severe lower back pain. She denies any history of trauma and has not experienced any problems with her bowel or bladder. In the last 24 hours, she has also developed some facial weakness and has been unable to sing. She denies any sensory disturbance, but mentions cutting her finger on a rose trellis while gardening in the last week. She has a past medical history of psoriasis and hypothyroidism, and takes regular thyroxine. On examination, she has mild bilateral facial weakness and ptosis, as well as mild weakness of shoulder abduction and adduction. Tone and sensation are intact, but reflexes are depressed. Lower limb examination reveals marked weakness throughout, reduced tone, and absent knee and ankle reflexes. Plantar responses are mute. Investigations reveal normal blood counts and electrolytes, as well as a slightly elevated ESR. A lumbar puncture shows elevated CSF protein. What is the likely diagnosis for this patient?

MRCP2-3104

A 26-year-old man presents to the Emergency department with a seven-day history of visual disturbance, specifically seeing double. He noticed that it was affecting his ability to drive safely. He had a previous transient numbness in his right arm, which resolved spontaneously after four weeks and was attributed to stress. He had no other significant medical history other than a hospital admission following a road traffic accident six years ago. He is a financial analyst, single, and lives alone. He smokes fifteen cigarettes per day, drinks thirty units of alcohol per week, and occasionally uses cocaine. On examination, he has impaired adduction of the right eye with nystagmus of the abducting eye, but the rest of the neurological examination is normal.

What is the most likely diagnosis?

MRCP2-3105

A 65-year-old man presents to a neurologist with a three-month history of progressive forgetfulness, agitation, and speech problems. He had been working as a shelf stacker in a supermarket but was recently made redundant due to increasing clumsiness with items. His wife has noticed him to be somewhat low in mood. On examination, he exhibits a marked expressive dysphasia with a receptive component and a left palmomental reflex. Peripheral nerve examination reveals marked generalised myoclonus and an intention tremor in the upper limb. In the lower limb, he exhibits a broad-based gait but no other features. Blood tests show abnormalities in sodium, creatinine, thyroid stimulating hormone, and vitamin B12 levels. What is the most likely cause of this patient’s symptoms?

MRCP2-3106

A 16-year-old girl presents after collapsing in a supermarket. She experienced hot and sweaty sensations, along with blurred vision before losing consciousness. Her mother reports that she was unresponsive and had limb twitching for twenty seconds before regaining consciousness. The patient has had three similar episodes in the past and her older brother has epilepsy. Although her ECG showed normal sinus rhythm, she felt nauseous and had urinary incontinence. What test is most likely to provide an accurate diagnosis?

MRCP2-3107

A 55-year-old construction worker visited his doctor complaining of weakness in his right shoulder and arm. He had difficulty lifting heavy objects above his head and had recently experienced reduced hand grip and numbness. These symptoms had gradually developed over the past two months after he fell from a plinth while working. The patient had a history of hypertension and mild asthma, smoked 20 cigarettes per day, and consumed 20 units of alcohol per week.

During the examination, the doctor observed winging of the right scapula and some wasting of the dorsal interossei and thenar eminence of the right hand. The patient had reduced tone in the right biceps and wrist, with absent biceps, triceps, and supinator jerks. Power testing revealed weakness in the right peri-scapular muscles, shoulder abduction, elbow flexion and extension, finger flexion and extension, and opposition of the thumb. Sensation was diminished over the thumb, right middle, ring, and little finger, extending over the medial and lateral aspect of the right forearm.

EMG and nerve conduction studies showed fibrillation potentials affecting small muscles of the right hand, with absent sensory nerve action potentials. Studies in the left arm were normal. Based on these findings, what is the most likely diagnosis?

MRCP2-3108

A 42-year-old homeless man is brought to the Emergency Department by the police. He claimed he was ill, with a headache, vomiting and neck and arm stiffness after being asked to move on from a shop doorway. On examination, he is pyrexial (37.8 °C) and has signs of mild meningism. Ophthalmoscopy reveals a small, grey–white choroidal nodule on the right-hand side and bilateral lateral rectus palsies are observed. Following neuroimaging, lumbar puncture is performed. Investigations reveal abnormal results for haemoglobin, white cell count, sodium, and protein. Magnetic resonance imaging (MRI) brain shows a small nodular enhancing lesion and chest X-ray (CXR) shows left upper lobe fibrosis/consolidation. Cerebral spinal fluid (CSF) analysis reveals elevated protein levels, lymphocytic cell count, and low glucose levels. Based on these findings, what is the most likely diagnosis?

MRCP2-3101

An 80-year-old man comes to the clinic with a festinant gait. His wife reports that he has been drooling saliva and his voice has become quieter over the past six months. During the examination, it is observed that he has a resting tremor in his right hand and increased rigidity in his right upper limb. What factor would make idiopathic Parkinson’s disease less likely in this case?

MRCP2-3094

A 25-year-old female presents with a persistent headache for the past eight weeks, which has worsened in the last week. She reports a constant frontal headache that is not relieved by paracetamol. The headache is present when she wakes up in the morning and persists throughout the day. Additionally, she has gained over 7 kg in weight in the last six months. On examination, she appears tearful and has a BMI of 32 kg/m2. However, there is no nuchal rigidity, and neurological examination is normal except for bilateral optic disc swelling on fundus examination. Her blood pressure is 122/88 mmHg, and her temperature is 37°C. What is the most appropriate investigation to make a diagnosis?

MRCP2-3095

A 55-year-old woman presents with a four-month history of slurred speech, unsteadiness of gait, and progressively worsening symptoms. She also experiences a tremor in her right hand and diplopia on right lateral gaze. She has a history of breast carcinoma and mild rheumatoid arthritis, for which she takes diclofenac. She smokes 30 cigarettes a day and drinks fewer than 10 units of alcohol per week. On examination, she has dysarthria, a right intention tremor, dysdiadochokinesis with past pointing, and a broad-based gait with a lean to the right. There is also evidence of a right VIth nerve palsy and mild facial weakness on the right side. Further investigations reveal abnormal CSF analysis with oligoclonal bands present and an MRI scan shows a calcified lesion attached to the petrous part of the temporal bone. What is the likely cause of this patient’s symptoms?

MRCP2-3096

A 50-year-old woman presented with a 6-month history of difficulty in swallowing. She had been well until 20 months ago when she noticed she could not hear as well in her left ear. Shortly after this, she noticed she could hear her heart beating loudly in her left ear. These problems had continued over the last year and a half but in the last 6 months she had also noticed problems in swallowing, particularly liquids. Her husband had commented that over the same time period her voice was much hoarser than it had been previously.

On examination she had a hoarse voice, wasting of the sternocleidomastoid and trapezius on the left and a decreased gag reflex. Rinne’s test showed AC > BC on the right and BC > AC on left (AC = air conduction, BC = bone conduction); Weber’s test lateralised to the left ear. The remainder of the neurological examination was normal.

What is the most likely diagnosis?