MRCP Part 2 Category: Neurology

MRCP2-3049

A 30-year-old woman presents to the Emergency department with sudden onset weakness and numbness affecting the left side of her face, arm, and leg. She experienced a typical migraine attack while out shopping with a friend, followed by the weakness and numbness. She did not experience any disturbance of consciousness, vision, or speech.

The patient has a history of troublesome migraines with aura and had a previous episode of right arm weakness six months ago, which lasted for 20 minutes before she recovered. She takes regular pizotifen 1.5 mg and Maxalt melt and is also on the oral contraceptive pill. There is a family history of migraine and strokes, and her mother died in her 50s with dementia. She smokes 10 cigarettes per day and does not drink any alcohol.

On examination, her blood pressure is 135/75 mmHg, pulse is 65/min and regular, and heart sounds are normal. Cranial nerve examination reveals left facial asymmetry and weakness with reduced sensation over the left face extending to the vertex. Pupils and fundoscopy are normal. Peripheral nervous system examination shows mild left hemiparesis of 4/5 with hyper-reflexia and left extensor plantar response. There is numbness to all modalities over the left arm and leg.

A brain MRI scan shows bilateral, multifocal, T2/FLAIR hyperintensities in the deep white matter. A lumbar puncture is performed, and the following data is obtained: opening pressure 8 cmH2O (6-18), CSF protein 0.35 g/L (0.15-0.45), CSF white cell count 3 cells per mL (≤5), CSF red cell count 2 cells per mL (≤5), CSF lactate 1.1 mmol/L (1-2), and CSF oligoclonal bands are negative.

What is the appropriate management plan for this patient based on her history and clinical findings?

MRCP2-3050

The likely diagnosis in this patient is polymyositis, a type of inflammatory myopathy that causes muscle weakness and inflammation. The symptoms of proximal muscle weakness, difficulty swallowing, and nasal regurgitation are characteristic of polymyositis. The elevated creatine kinase level and abnormal EMG findings also support this diagnosis. The left hilar mass seen on chest x-ray may be unrelated or could suggest an underlying malignancy associated with the polymyositis. Further investigations, such as a muscle biopsy and imaging studies, may be necessary to confirm the diagnosis and identify any underlying causes.

MRCP2-3051

A 15-year-old boy is brought to the emergency department by his mother after experiencing brief episodes of unresponsiveness while walking. He has no memory of these episodes. At the age of 10, he was diagnosed with absence seizures and was prescribed anti-epileptics. These were gradually discontinued by his neurologists two years ago after being seizure-free for three years.

In the last 48 hours, he has had four of his typical absences. As a healthcare provider, you decide to prescribe an anti-epileptic. What antiepileptic medication should you avoid?

MRCP2-3052

A 33-year-old woman with no prior history of seizures is referred to the neurology team after experiencing two episodes. The team prescribes carbamazepine, but three weeks later, she has several more seizures despite being fully compliant with the medication. She has a medical history of asthma and gastro-oesophageal reflux disease, for which she uses salbutamol and beclometasone inhalers, montelukast, cimetidine, and omeprazole. Additionally, she takes the combined oral contraceptive pill. Which of these medications may have contributed to the recurrence of her seizures?

MRCP2-3053

A 46-year-old man is admitted to the hospital after experiencing a tonic-clonic seizure. He has a medical history of epilepsy, gastro-oesophageal reflux, and latent TB. His current medications include sodium valproate, omeprazole, isoniazid, and carbamazepine, which was started 4 weeks ago due to poor seizure control. Additionally, he regularly consumes moderate-large amounts of grapefruit juice. Following his recovery and a Glasgow coma scale score of 15/15, a CT head scan was performed, which showed no abnormalities. What substance is responsible for causing his seizures?

MRCP2-3054

A 55-year-old woman presents with a persistent headache that has lasted for 4 months. She recently experienced a discharge from her left ear, which was diagnosed as Aspergillus fumigatus and treated with eardrops. However, she now reports double vision and sciatic pain in her left leg. She has a history of breast cancer and is currently taking Tamoxifen. On examination, she has bilateral papilloedema, paretic lateral recti, and a mild facial paresis on the left side. Her ankle jerk is hypoactive and planters are flexors on both sides. Further investigations reveal scattered leptomeningeal enhancement on an MRI brain scan and elevated levels of ALT and ESR. The CSF analysis shows elevated protein and lymphocytes, but no malignant cells or evidence of infection. What is the most likely diagnosis?

MRCP2-3055

You assess two new patients in the Cerebrovascular Clinic.
Mrs X is a 70-year-old woman with background hypertension. She has had one episode of presumed left amaurosis fugax one week previously. Carotid Doppler ultrasound scanning shows a 76% stenosis of the left internal carotid.
Mr Y is a 74-year-old man with stable angina and peripheral vascular disease. Three days previously he had a transient episode of dysphasia lasting 20 min. Carotid Doppler ultrasound scanning shows a 75% stenosis of the left internal carotid.
Who would benefit most from carotid endarterectomy?

MRCP2-3056

A 50-year-old woman visited her GP with complaints of tingling in her right palm and pain in her right wrist. She had been experiencing these symptoms on and off, but they had recently become severe enough to keep her up at night. She had also noticed a decrease in her grip strength, making it difficult for her to work at the checkout counter in her local supermarket. Apart from these symptoms, she felt fine and had not experienced any weakness in her lower limbs or other hand.

The patient had a stable weight and denied any issues with her neck or swallowing. She had a medical history of hypothyroidism and hypertension and was taking regular medication for these conditions. She was a non-smoker and only drank alcohol occasionally.

During the examination, the patient appeared alert and oriented. Her fundoscopy and cranial nerve examination were normal, and she had full neck movements. However, there was wasting over the right thenar eminence and fasciculations with a small burn over the right index finger. No other fasciculations were detected in the proximal limb or other hand. Tone appeared normal, and reflexes were intact. There was weakness of thumb abduction and opposition, with loss of pinprick and light touch sensation over the thumb, index, and middle finger in the right hand. No abnormalities were found during the examination of the lower limb.

Nerve conduction studies revealed an absent sensory action potential in the right median palmar branches and denervation of the right abductor pollicis brevis. Sensory and motor conduction studies in the left upper limb and lower limbs were normal.

What is the most likely diagnosis?

MRCP2-3057

A 16-year-old girl was referred to a neurologist due to experiencing multiple episodes of collapse. According to her mother, these episodes lasted from a few seconds to one minute, during which the girl would suddenly collapse and become limp. In the past month, she had experienced one episode during an argument with her boyfriend, another while watching football on TV, and another while laughing with her sister. During one of these episodes, she also had visual hallucinations. The patient claimed that she had never lost consciousness during these episodes, but she did report feeling unable to move several times after waking up in the morning. What is the most probable diagnosis?

MRCP2-3058

A 58-year-old male construction worker presents with sudden and severe lower back pain. He has no history of orthopedic issues and has been in good health until now. The patient reports experiencing tingling sensations in his lower limbs and has not been able to urinate since the onset of the pain. Upon neurological examination, weakness (3/5 of both lower limbs) and loss of sensation to touch in L4, L5, and S1 are observed. Vibration sensation and joint position sensation are intact, but reflexes in the ankles and knees are absent and the plantar response is uncertain. The patient’s blood pressure is 160/70 in his left arm and 152/64 in his right, heart rate is 96 bpm, temperature is 37°C, and ECG shows normal sinus rhythm with no signs of ischemia. The rest of the examination is unremarkable. What diagnostic test would be most helpful in determining the cause of the patient’s symptoms?