MRCP Part 2 Category: Neurology

MRCP2-3097

A 25-year-old woman presents to her GP with progressive unsteadiness, numbness, and weakness in her lower legs, as well as slurred speech. She reports a history of being clumsy as a child and follows a vegan diet. On examination, she has dysarthria, bilateral optic atrophy, and horizontal nystagmus. Her upper limb reflexes are depressed, and there is reduced vibration sense. In her lower limbs, she has bilateral pes cavus, distal muscle wasting, absent ankle and knee jerks, and a pyramidal distribution of weakness. Sensory examination reveals reduced vibration and joint position sense. Her gait is ataxic, and Romberg’s test is positive. Blood tests show elevated glucose levels, and a double apical impulse and ejection systolic murmur are noted on cardiovascular examination. CSF analysis reveals elevated protein levels but no oligoclonal bands. What is the likely diagnosis?

MRCP2-3098

A 50-year-old man presents with a six-month history of proximal weakness in both upper and lower limbs, dry mouth, and impotence. He is a heavy smoker, consuming 30 cigarettes per day, and drinks 12 units of alcohol per week. Apart from this, he has been healthy. On examination, he is an obese individual with a blood pressure of 155/90 mmHg and is apyrexial. Chest, heart, and abdominal examination are normal. There is proximal weakness grade 4/5 in both upper and lower limbs. The reflexes are generally depressed, plantars are flexor, and sensation is normal. What is the most likely diagnosis?

MRCP2-3099

A 40-year-old female presents with a history of feeling fatigued after mild exertion for the past six months. She has also been experiencing difficulty with attention. Despite being diagnosed with fibromyalgia and attempting graded exercise, she has not noticed any improvement and seeks further opinion.

On examination, the patient appears to be in reasonable health with a BMI of 29 and a blood pressure of 128/84 mmHg. She exhibits partial ptosis on the right side of her face, along with nasal speech that worsens with sustained activity. Her pupillary size and reaction are normal, and her deep tendon reflexes are normal throughout. The patient’s anti-acetylcholine receptor antibody test was negative.

What investigation would be appropriate to confirm the clinical impression?

MRCP2-3100

A 28-year-old woman presents to her GP with her boyfriend. She reports that over the past few months, her boyfriend has been hearing voices that demand him to do things or simply hum or laugh. He also believes that she is plotting to leave him for his brother and that he has a deadly illness with less than a year to live. These delusions have caused significant strain on their relationship, and he has lost weight, become increasingly nervous, and neglected his appearance. He has no known medical problems, is a smoker of 20 cigarettes per day, and drinks 15 units of alcohol per week. On examination, he appears withdrawn and unkempt, fidgeting with his clothes and commenting on a fishy smell. His mini-mental state examination score is 30/30, and there are no abnormalities on cranial nerve or peripheral nervous system examination or on an MRI scan of his brain. What is the most likely diagnosis for this patient?

MRCP2-3093

A 25-year-old female patient presents with a medical history of recurring episodes of dysarthria, ataxia, and diplopia lasting for 20-30 minutes, followed by a severe headache on the right side accompanied by vomiting that lasts for one to three days. These episodes occur once every month. The patient’s MRI brain and MR angiogram results are normal. What is the probable diagnosis?

MRCP2-3079

A 20-year-old male presents to the clinic with a 4-month history of worsening speech slurring. He is feeling extremely embarrassed and is often mistaken for being drunk by his college friends. He is also experiencing excessive drooling and has noticed increasing weakness in lifting his right arm over the past 8 weeks. He has no significant medical history, does not smoke, and only drinks alcohol socially.

During the examination, he demonstrates weakness in raising his eyebrows, puffing his cheeks, and pursing his lips. He also displays significant scapula winging bilaterally with mild wasting of his right deltoid muscle. The musculature of his left arm is normal. The power of his right shoulder abduction and adduction is 3/5, with 5/5 in all other movements. Reflexes are all present with a normal sensory examination.

His blood tests reveal:

– Hb 142 g/l
– Platelets 390 * 109/l
– WBC 6.0 * 109/l
– Na+ 140 mmol/l
– K+ 4.5 mmol/l
– Urea 4.8 mmol/l
– Creatinine 60 µmol/l
– CRP 3 mg/l
– Creatine kinase 155 IU/l (50-335)
– TSH 2.5 mu/l
– HIV negative

What is the most likely diagnosis?

MRCP2-3080

A 70-year-old man is brought to the hospital by his wife due to increasing vagueness and a headache the day before. He has a history of Parkinson’s disease and has been consistent with his medication. He was born in Russia and has been exposed to tuberculosis in his younger years. He immigrated to the UK twenty years ago and has not traveled abroad in the last year. On examination, he is very sleepy and unable to recall his history. His chest is clear, but he has a temperature of 38.2ºC. His blood work shows elevated CRP and WBC levels. A lumbar puncture reveals mononuclear cells. CT head shows no acute intracranial or extracranial bleed. What is the likely diagnosis?

MRCP2-3081

A 75-year-old man presents to the Emergency Department after a fall. He was discovered on the floor by his caregiver after attempting to go to the kitchen. This is his third visit to the Emergency Department in the past 4 months. He has a medical history of hypertension, managed with Ramipril and Indapamide, and Type 2 diabetes treated with Metformin. On examination, his blood pressure is 135/85 mmHg with no postural drop, and his pulse is regular at 75/min. He displays bradykinesia and bilateral increased tone, more pronounced on the right side. A resting tremor is also present. When asked to walk, he is slow to start and unable to cross the threshold of the clinic room door. His mini-mental state examination score is 25/30.
What is the most probable diagnosis?

MRCP2-3082

A 32-year-old man presents to the Emergency Department with a sudden and severe headache that reached its peak intensity within seconds of onset. The pain is the worst he has ever experienced. The headache has been present for six hours but is now subsiding. He reports associated nausea, vomiting, and sensitivity to light.

The patient has no significant medical history and has never experienced a severe headache before. Upon examination, there are no notable findings. The casualty officer has already performed several tests, including a lumbar puncture, which was difficult and resulted in a bloody tap. A CT scan of the brain was normal, and the spinal fluid analysis showed 500 RBC/cm3, < 5 WBC/cm3, no organisms on Gram stain, and no xanthochromia. What is the next most important step in managing this patient?

MRCP2-3083

A 65-year-old man presents to the hospital with a five-day history of headache, nausea, confusion, somnolence, and left leg weakness that had been progressively getting worse over several weeks. He is also being investigated for weight loss and shortness of breath. On examination, he appears confused and disorientated with evidence of axillary and cervical lymphadenopathy and a mass over the left chest. Neurological examination reveals left-sided lower limb paresis with hypertonia and hyperreflexia. A chest x-ray shows multiple lung lesions, and an MRI scan of the brain shows meningeal enhancement, enhancement of the basilar cisterns, and multiple enhancing masses with marked surrounding oedema. The patient has a past medical history of arthritis in the knees and hands and had been looking after his mother who had recently died of breast carcinoma. He had worked as an electrician all his life and was a non-smoker and did not drink alcohol. What is the most likely diagnosis?