A 16-year-old Caucasian male with no prior medical history presents with his first episode of sudden onset left leg weakness and numbness on his anterior left thigh, which has persisted for 5 days. Upon examination, it is noted that he has 3/5 weakness on flexion of his left hip and loss of sensation to light touch, pain, and temperature on his anterior left thigh in the sensory nerve root L1 distribution. A contrast MRI scan of the patient’s spine reveals a hyperintense T2 signal partially within the left side of the cord at the L1, with corresponding enhancement with gadolinium. No masses were observed. Further imaging of the brain is pending. What is the most probable diagnosis at this time?
MRCP2-3551
A 75-year-old male visits the PD clinic with a complaint of uncontrollable jerking and flailing movements in his arm, which he finds embarrassing and disabling. He reports minimal issues with ‘off’ periods and few other PD symptoms. His medical history includes PD diagnosed 6 years ago and type 2 diabetes. He is currently taking Sinemet 250 for Parkinson’s disease 5 times a day and metformin 500mg TDS, with no changes in Sinemet dosage for the past 18 months. What is the most appropriate course of action for management?
MRCP2-3552
A 57-year-old man is brought to the hospital by his wife due to unusual behavior. She found him repeatedly cutting the same shrubs while gardening and he kept asking when dinner would be ready. When he returned to the house, he had no recollection of gardening and continued to ask the same questions repeatedly.
Upon examination, he appears to be well and oriented in time and place, but a little confused about what happened. There are two beats of nystagmus seen, but no ophthalmoplegia. He has normal limb power, tone, and gait, with no myoclonus or fasciculations. His wife reports no memory problems or personality changes prior to this incident. He denies excessive alcohol use, but his father was diagnosed with Alzheimer’s disease at the age of 60.
Lab results show normal electrolyte levels, kidney function, and blood counts, but low levels of B12 and slightly elevated bilirubin and ALP. A CT scan reveals age-related changes and old lacunar infarcts on the left side, but no intracranial hemorrhage.
What is the likely diagnosis for this 57-year-old man’s unusual behavior?
MRCP2-3553
A 67-year-old man presents to the Emergency Department with sudden memory impairment that started 3 hours ago. His wife reports that he became disoriented after taking a cold shower and complained of a mild headache. On examination, his vital signs are stable and he is alert but disoriented in place and time. He can recall his identity but has difficulty remembering three objects after 3 minutes. There is retrograde amnesia for several hours. The following day, he has fully recovered and all laboratory tests are normal. What is the most likely diagnosis?
MRCP2-3554
A 67-year-old man presents to neurology clinic for evaluation of his long-standing trigeminal neuralgia. He has been experiencing symptoms for five years and has been frequently reviewed by neurology, but his condition has not improved. The patient suffers from severe shooting pain affecting the right side of his lower face, with each episode lasting about an hour. The frequency of attacks has increased over time, and he now experiences four to five episodes per week. The patient’s symptoms have significantly impacted his quality of life, and he rarely leaves his house due to fear of an attack.
Carbamazepine was initially prescribed four years ago, which provided some relief, but the patient was intolerant due to drowsiness. Subsequent trials of oxcarbazepine, lamotrigine, and baclofen did not provide lasting relief. The patient was recently diagnosed with depression and started on sertraline. He also has type 2 diabetes, which is managed with diet and metformin 500 mg TDS. The patient has been unable to work as a school-teacher for the past two years due to his symptoms. Although he was previously hesitant to consider surgical intervention, he is now willing to try any options that could improve his symptoms.
MRI brain with/without contrast showed no evidence of inflammation, space-occupying lesion, extra-cranial mass along the course of trigeminal nerves, widespread demyelination plaque, or previous infarction. There was also no abnormal enhancement of the trigeminal nerves.
What is the most appropriate surgical intervention for this patient?
MRCP2-3555
A right-handed smoker in his 60s is referred by his general practitioner for assessment of likely stroke. His wife reports a sudden onset of left-sided weakness and bumping into objects on the left.
Upon examination, you observe left-sided motor weakness, sensory inattention, and a possible field defect. However, the patient’s restlessness prevents you from determining the field defect accurately. You admit him to the hospital and arrange for brain imaging. While waiting for imaging, the neuro-ophthalmology team evaluates him and formally plots his visual fields.
What type of visual field defect do you anticipate?
MRCP2-3541
A 50-year-old female presents with bilateral tingling sensation in her medial one and half digits at night, along with clawing of her 4th and 5th digits. She is concerned about the cosmetic aspect of her condition. Additionally, she has been experiencing left-sided foot drop for the past 8 months. Her medical history includes type 2 diabetes mellitus, for which she takes metformin 850mg TDS, but admits to occasional poor compliance. Her last HbA1c was 53 mmol/mol. She has had multiple surgeries on her feet during childhood, but does not remember the details. She was adopted and has no knowledge of her birth family history. On examination, she has a left common peroneal palsy, thin calves bilaterally, and loss of sensation in bilateral ulnar nerve territories. What is the underlying diagnosis for her symptoms of paraesthesia and foot drop?
MRCP2-3526
A 70-year-old man presents with sudden onset expressive dysphasia and right hemiparesis. He has a history of smoking 20 cigarettes per day and drinking ten units of alcohol per week. He is also hypertensive and takes 2.5 mg of bendroflumethiazide. On examination, he has expressive aphasia, right-sided homonymous hemianopia, and a right extensor plantar response. CT brain shows a left middle cerebral artery territory ischemic stroke. His ECG shows sinus rhythm, and Doppler of carotids shows 20-30% stenosis of the right internal carotid artery and 40% stenosis of the left internal carotid artery. He has been started on aspirin 300 mg per day and simvastatin 40 mg on the day of admission. All investigations have been completed by day three of his admission. What is the next most appropriate step in management?
MRCP2-3527
A 73-year-old man presents to clinic following a recent cerebral infarct. He has a history of heavy smoking and hypertension, managed with ramipril. Despite some left-sided motor weakness and spasticity affecting his hand, he is able to independently perform daily activities. A carotid Doppler revealed 90% stenosis of the right internal carotid. He is currently taking clopidogrel. What is the most suitable course of treatment for this patient?
MRCP2-3528
A 42-year-old male comes to your headache clinic complaining of daily left-sided headaches for the past 8 months. The pain is located in the frontal and retroorbital area and he reports no pain-free periods. The headaches are moderate in severity, typically 5/10, but occasionally worsen to 9/10. He also experiences left-sided conjunctival injection and lacrimation during the headaches. What diagnostic tool would be most helpful in determining a diagnosis?