MRCP Part 2 Category: Neurology

MRCP2-3072

You have been referred a 40-year-old man by the Accident and Emergency doctors with a severe headache. The headache woke him up at 3am, and he describes it as the worst headache he’s ever had, (although he admits he’s not a regular headache sufferer). He has had seven episodes like this over the past two weeks that have followed a very similar pattern, with the other two headaches lasting around 60 minutes before going.

The pain is mainly around the left eye and temple and is sharp in nature. You have to ask him to sit down to examine him because he is up and pacing around his room, clearly very agitated. On examining him you note that his left eye is watering and swollen, and there’s some redness and mild bruising just above the eye. When you ask him about this bruising he says that the pain was so bad he bashed his head against the fridge door to try and help take it away.

On examination he has normal power, sensation and reflexes in all four limbs. On examining his cranial nerves you notice that he has a mild left sided ptosis and miosis, and there is conjunctival injection and lacrimation on that side too.

What is the most likely cause of his headache?

MRCP2-3073

A 45-year-old man presents to his GP with recurrent severe headaches. The headaches occur episodically every three to six months, with daily headaches lasting up to eight weeks at a time. The patient reports being woken up at 2 am with severe right peri-ocular pain, which typically lasts for 30-60 minutes. During these attacks, he also experiences right-sided nasal congestion and lacrimation. The patient denies nausea, vomiting, photophobia, or phonophobia. He is a business executive, a smoker of 20 cigarettes per day, and drinks 30 units of alcohol per week. On examination, there is mild right-sided ptosis, red and watery right eye, and pupillary constriction. The rest of the cranial nerves appear intact, and fundoscopy is normal. There are no abnormalities detected on the peripheral nervous system examination. The MRI brain and MR angiography are normal. What is the most likely treatment to alleviate this patient’s acute symptoms?

MRCP2-3074

You are requested to assess a 26-year old female who has just given birth on the labour ward. Her baby boy was born with severe hypotonia and needed resuscitation and ventilation. Upon examination, she displays bilateral ptosis, global weakness (with more pronounced distal weakness), and bilateral cataracts. She mentions that her father had bilateral cataracts and passed away at the age of 59. What is the probable diagnosis for the mother?

MRCP2-3075

A 32-year-old woman has been feeling unwell for the past 8 months. Her partner accompanies her to the Psychiatry Clinic to provide additional information about her condition. The symptoms are recurrent, with repetitive behavior during each episode. She experiences sudden confusion and begins to chew her nails. She moves around and resists any attempts to restrain her physically. After a few minutes, she recovers but has no memory of the preceding moments. She reports having had febrile convulsions as a child, but there is no family history of epilepsy. The psychiatric examination is normal.

What is the most likely diagnosis?

MRCP2-3076

A 42-year-old Asian man presented to the hospital after experiencing three generalised seizures. He had been complaining of headaches, increased thirst and urination, and sudden weakness in his right arm and leg. Over the past week, he had become increasingly confused and lethargic. The patient had a history of hypertension and was taking bendroflumethiazide. He also smoked 30 cigarettes per day and had recently seen his GP for arthritic pain in his back and knees.

Upon examination, the patient appeared dehydrated with decreased skin turgor and dry mucous membranes. He had a left lower motor neurone facial nerve palsy and red, inflamed eyes. Peripheral nervous system examination revealed a right-sided hemiparesis with brisk reflexes and a mute left plantar response.

Investigations revealed a left anterior circulation infarct on a CT scan of the brain, as well as bilateral hilar lymphadenopathy and fibrotic interstitium on a chest x-ray. The patient’s CSF analysis showed elevated protein and lymphocytes, as well as positive oligoclonal bands.

What is the likely diagnosis for this 42-year-old Asian man?

MRCP2-3061

A 26 year-old man with ataxia telangiectasia undergoes open biopsy of an enlarged axillary lymph node. Microscopic examination reveals changes consistent with nodular sclerosing Hodgkin’s disease. Regrettably, he develops spreading cellulitis around the biopsy site which does not improve with intravenous antibiotics and ultimately necessitates surgical debridement.

What is the primary cause for the heightened vulnerability to infections in individuals with ataxia telangiectasia?

MRCP2-3046

A 25-year-old female presented to the Emergency department with a five-day history of progressive weakness and lethargy. She initially complained of a constant dry mouth and nausea with some swallowing difficulties. Over the last few days, she has experienced blurring of vision and upper limb weakness, as well as breathlessness on exertion. She also reported a sore throat and abdominal pain, which she attributed to her period. The patient denied any medical problems but was a smoker of 20 cigarettes per day.

On examination, the patient was alert and orientated with evidence of intravenous drug abuse. Cranial nerve examination revealed mild bilateral ptosis, restricted ocular movements on right lateral and right superior gaze, reduced palatal movements, and weak neck extension. Upper limb examination showed reduced reflexes bilaterally with some proximal weakness, while lower limb examination showed depressed reflexes with normal power and sensory examination. Chest examination was normal, but abdominal examination was not performed.

A full blood count and biochemical profile were normal. Lumbar puncture showed an opening pressure of 12 cm H2O (5-18), protein of 0.65 g/L (0.15-0.45), white cell count of 3 per ml (≤5), and red cell count of 2 per ml (≤5). The Tensilon test was positive.

What is the likely diagnosis for this 25-year-old female patient?

MRCP2-3062

A 55-year-old woman is brought to the hospital after collapsing suddenly, with a severe headache preceding the incident. Upon arrival at the Emergency Department, her Glasgow Coma Scale (GCS) has improved to 13, and a CT scan confirms a subarachnoid hemorrhage.

You are summoned to assess her 72 hours after admission because her GCS has progressively declined to 8 over the past hour. She is currently breathing air, and her SpO2 is at 97%.

What is the most probable cause of this secondary deterioration?

MRCP2-3047

How can the brain stem death testing be correctly paired with the relevant nerves?

MRCP2-3048

A 56-year-old woman presents to the Emergency Department following a seizure that occurred while she was a passenger in a car. There is no history of trauma. Upon admission, she is alert with a GCS of 15/15. Her partner reports a generalised seizure with a post-ictal phase lasting approximately 30 minutes. On examination, her heart rate is 90/min, blood pressure is 102/60 mmHg, and temperature is 37.1ºC. There are no focal neurological signs. A MRI scan is ordered:

What is the most likely diagnosis?