MRCP Part 2 Category: Neurology

MRCP2-3037

A 50-year-old male presents to the emergency department with persistent confusion over the past 3 weeks. He has a known history of HIV and has been compliant with his medications since his diagnosis 4 years ago. His past medical history includes outpatient treatment for lymphogranuloma venereum and type 2 diabetes mellitus. On examination, he is disoriented in time and place and scores 0/10 on the abbreviated mental test. A mild early diastolic murmur is heard on cardiac examination. Neurological examination reveals absent reflexes in both lower limbs, with an upgoing plantar on the left and withdrawn plantar on the right. Erythematous soles are noted on both feet. Blood tests and blood glucose are pending. What is the most likely diagnosis?

MRCP2-3038

A 29 year old female presents to the general medical clinic with a one year history of severe right-sided headaches. She reports experiencing eyelid swelling and lacrimation during these attacks, which never occur on the left side. The paroxysms last for approximately 2 minutes and can occur more than 10 times per day. The patient experiences these attacks every day for a week or two, with a month or so between attacks. She denies any associated nausea or vomiting.

What management options should be considered for this patient?

MRCP2-3039

A 32-year-old male of Mediterranean descent presents to the Emergency department with complaints of progressive unsteadiness and double vision. He has also experienced weakness in his left arm and leg, accompanied by a throbbing headache. The patient has a history of joint pains and oral ulcers, and recently visited his GP for a rash on his shins. On examination, he appears unsteady and has herpetiform oral ulcers and bilateral red eye. There is evidence of right facial weakness and restricted abduction of the right eye. The upper limb shows increased tone on the left with mild pyramidal weakness of 4/5 and hyperreflexia. The lower limb has nodular lesions over both legs, with slightly increased tone on the left and some pyramidal weakness of 4/5 with a left extensor plantar. Sensory examination is normal, but the patient exhibits a broad-based ataxic gait. An MRI scan of the brain shows inflammatory white and grey matter lesions within the fronto-parietal lobes and a single lesion within the pons. The CSF opening pressure is 140 mmH2O, and the CSF protein is 1.2 g/L with a white cell count of 120 (80% lymphocytes). Blood tests show elevated C reactive protein and erythrocyte sedimentation rate. What is the likely diagnosis for this patient?

MRCP2-3040

The disease defining test in this case would be a lumbar puncture to analyze the cerebrospinal fluid (CSF) for signs of meningitis. The CSF analysis in this case shows elevated red blood cells (RBCs) and normal white blood cells (WBCs), indicating a possible subarachnoid hemorrhage. However, further tests such as CT or MRI may be needed to confirm the diagnosis.

MRCP2-3041

A 45-year-old woman presents with a six-week history of brief episodes where she feels like the room is spinning around her. These episodes are most severe when she lies on her right side with her ear down and are accompanied by nausea. She reports no issues with hearing or tinnitus. On examination, she exhibits rotatory nystagmus that begins several seconds after assuming the right lateral decubitus position and resolves after a minute. Repeated positioning in the same position results in the attenuation of the nystagmus. Audiometry testing shows normal hearing. What is the likely diagnosis for this patient?

MRCP2-3042

A 65-year-old woman presents with paroxysmal dizziness characterized by episodes of room spinning. The symptoms worsen when she rolls over to the right in bed or reaches above her head. She reports no other symptoms. Upon neurological and general medical examination, no abnormalities are found. The vertigo can be induced by turning the patient’s head 45 degrees to the right and then moving them to a supine position. Nystagmus (upbeating and torsional) is present for only a few seconds. What is the diagnosis?

MRCP2-3043

A 25-year-old medical student is being evaluated for severe headache and stiffness in the neck. The on-call doctors have recommended an LP after a normal CT scan, but the patient is concerned about developing a post-lumbar puncture headache. What technique has been demonstrated to decrease the occurrence of this type of headache and would be appropriate for this patient?

MRCP2-3044

A 32-year-old man presented with gradual difficulty walking and blurry vision over the course of 3 weeks. The day before admission he became excessively sleepy, but still able to be awakened. His partner reported that he had been healthy except for a recent viral illness a month ago.

During the examination, he appeared slightly disoriented and drowsy. His vital signs were normal and there were no abnormalities found during cardiovascular, respiratory, or abdominal examinations. He had reduced upward gaze and bilateral abduction, but all other cranial nerves were normal. His limb examination was unremarkable except for brisk reflexes and up-going plantars.

What is the most probable diagnosis?

MRCP2-3029

A 75-year-old man presents to the Emergency department with weakness affecting both legs. The weakness had been preceded by a sudden onset of left sided hip pain, which had become intractable over the last four hours. He had also developed numbness over both legs to the level of the sternum. He had a past medical history of hypertension and ischaemic heart disease and took atenolol and Suscard buccal when required. He was a smoker of 10 cigarettes per day and drank a whiskey a night.

On examination, he appeared in distress. What is the likely cause for this patient’s symptoms?

MRCP2-3014

You receive a call from a GP in the community regarding a 67-year-old female patient who was diagnosed with generalised myasthenia gravis six years ago. She was last reviewed in neurology outpatients 6 weeks ago and reports no improvements in her neck weakness, voice weakness and fatigue. Her pyridostigmine dose was increased from 90 mg QDS to 120mg QDS in the neurology clinic. Although she does not appear acutely unwell, she complains that her symptoms significantly affect her life. She has no other past medical history. During examination by her GP, she shows no signs of respiratory distress and is able to swallow salivary secretions normally. What advice would you give in this situation?