MRCP Part 2 Category: Neurology

MRCP2-3084

A 29-year-old man was admitted to the hospital with altered consciousness and aggressive behavior. He had been in a car accident three days prior, driving at 70 mph in a residential area and crashing into a garden wall. He had fled the emergency department before any investigations were conducted, despite smelling strongly of alcohol. His family reported that he had no regular medication but suffered from recurrent sinusitis and had recently taken antibiotics. He was unemployed and prone to heavy drinking. Upon admission, he had a Glasgow Coma Scale of 13/15 and appeared disheveled, flushed, and uncooperative. He had lacerations on his face and left temporal region, and his vital signs were elevated. A CT scan revealed a lesion in the left frontal lobe, and a lumbar puncture showed abnormal CSF findings. Based on this clinical presentation, what is the most likely diagnosis for this patient?

MRCP2-3085

A 28-year-old man presented with a 6-day history of progressive weakness. Initially, he developed a foot drop on the left and some weakness of hand grip on the right, but over the next few days this progressed to weakness of all four limbs. He had just returned from a two-week holiday to Italy where he had spent the first few days in bed with a cough and feeling generally unwell.

On examination, there was weakness, decreased tone and areflexia in all four limbs. Plantar responses were downgoing. Cranial nerves, coordination and sensation were normal.

What is the most useful investigation to make a diagnosis in this case?

MRCP2-3086

A 32-year-old flight attendant visited her primary care physician reporting intense headaches and vision impairment. She is currently taking medication for facial acne and is also on the oral contraceptive pill. During the examination, her weight was recorded as 70 kg, height 152 cm, and blood pressure as 136/82 mmHg. Bilateral papilloedema was observed.
What would be the most suitable course of action for diagnosing the condition after conducting a CT scan of the brain?

MRCP2-3087

A 32-year-old man presented with a 8-month history of vision blurring when bending forward. He also reported experiencing worsening headaches in the morning for the past 6 months. Apart from that, he had no other health issues. Upon examination, he had a body mass index of 30 and no other abnormalities were found. However, bilateral papilloedema was observed during neurological examination. An MR venogram was conducted, but the results were normal. What would be the most suitable next step in investigation?

MRCP2-3088

A 42-year-old woman presents to the Emergency department with a sudden onset severe headache accompanied by nausea and vomiting. She has also experienced intermittent uncontrollable twitching of her left hand and noticed blurring of vision in the last hour. The patient has a history of psoriatic arthropathy and is recovering from gastroenteritis. She is a smoker and drinks approximately 10 units of alcohol per week. On examination, she appears dehydrated with mild papilloedema and increased tone in the left arm and leg. A CT brain scan reveals an enhancing lesion within the right frontal cortical white matter junction associated with haemorrhage and cerebral oedema. Based on these findings, what is the most likely cause of the patient’s neurological presentation?

MRCP2-3089

A 40-year-old man visits his primary care physician with a history of occasional difficulty speaking and reduced facial expressions. He also reports occasional regurgitation of food through his nose, which he finds embarrassing. His symptoms are most severe at the end of the day. He has no significant medical history and takes no regular medications.
During the examination, his vital signs are normal. His heart and lungs are functioning normally, and he has no motor or sensory deficits. He reports blurred vision during visual field testing.
What is the initial investigation to request, given the probable underlying diagnosis?

MRCP2-3090

A 55-year-old woman presents to the Emergency department with progressive weakness and numbness in both legs. Her symptoms have developed over the course of a week, and she has also noticed numbness and weakness in her hands, double vision, and weakness in her facial muscles. She has a history of rheumatoid arthritis and was recently diagnosed with diabetes due to long-term steroid use. On examination, she has cushingoid features, restricted left lateral gaze, bilateral facial weakness and dysarthria, reduced tone in the upper limbs, marked weakness of handgrip and wrist flexion/extension bilaterally, absent reflexes, and sensory loss to all modalities extending up to the elbow bilaterally. In the lower limbs, she has flaccid tone bilaterally, some wasting and weakness of the proximal muscles, marked weakness of dorsiflexion and plantarflexion of the foot bilaterally, absent reflexes, and reduced sensation to all sensory modalities extending to the knee bilaterally. Blood tests show normal sodium and urea levels, low potassium levels, elevated creatinine levels, and high HbA1c levels. The erythrocyte sedimentation rate is also elevated, and the lumbar puncture shows elevated CSF protein levels and low CSF glucose levels. How would you initially manage this patient?

MRCP2-3091

A 65-year-old man presents to the neurology clinic with complaints of excessive daytime drowsiness despite good sleep patterns. His wife reports that he appears vague and drowsy at times during the day, with fluctuating attention span. He has also been experiencing visual hallucinations and has become increasingly slow at dressing and walking. His medical history includes hypertension treated with bendroflumethiazide and a previous left-sided cerebrovascular accident with good recovery. He is a smoker and drinks 10 units of alcohol per week. On examination, he has a small goitre and hypophonia with an expressionless face. His mini mental state examination reveals deficiencies in verbal fluency, executive function, and visuospatial testing. Peripheral nervous system examination reveals bradykinesia, increased tone bilaterally, and unilaterally brisk reflexes on the left with delayed relaxation on the right. The left plantar response is extensor. Thyroxine levels are low, and thyroid stimulating hormone levels are high. What is the best next step in managing this patient?

MRCP2-3092

A 45-year-old woman presented to her GP with complaints of visual impairment. She had been experiencing difficulty navigating around furniture for some time. She also reported worsening headaches over the past two weeks and had recently experienced two complex partial seizures. Her medical history included partial epilepsy diagnosed at 20 years of age and treatment with vigabatrin. She was currently taking lamotrigine and smoked 10 cigarettes per day and drank 8 units of alcohol per week. On examination, she had a marked bitemporal inferior quadrantanopia and some paraesthesia affecting the left ophthalmic branch. Investigations revealed elevated prolactin levels. What is the likely diagnosis?

MRCP2-3077

You are requested to evaluate a 15-year-old Caucasian girl who has been feeling unwell for a few days. She has been experiencing intermittent fevers and chills and complains of extreme fatigue. Suddenly, half an hour before her admission to the hospital, she lost all vision in her left eye.

During the examination, the patient appears pale and unwell. Her vital signs are as follows: temperature 38.5°C, pulse 120/minute, regular, blood pressure 100/55 mmHg, and respiratory rate 22/minute. A pansystolic murmur is audible at the apex and lower left sternal border. Both lungs are clear.

The right pupil reacts normally to light, but there is no reaction from the left pupil, which remains fixed and dilated. The patient has complete loss of vision in the left eye, and the left fundus appears paler than the right, with no papilloedema. The only additional finding on examination was a paronychia on her right thumb, and light pressure on the nail bed was very uncomfortable.

Investigations reveal the following results: Hb 109 g/L (115-165), WBC 14.1 ×109/L (4-11), Neutrophils 9.0 ×109/L (1.5-7), Lymphocytes 4.8 ×109/L (1.5-4), Monocytes 0.29 ×109/L (0-0.8), Eosinophils 0.01 ×109/L (0.04-0.4), and Platelets 550 ×109/L (150-400).

What is the most crucial investigation to determine the cause of her illness?