MRCP Part 2 Category: Neurology

MRCP2-3015

An 88-year-old woman presents to the emergency department with unilateral weakness and difficulty in naming objects, as reported by her family. This began approximately six hours ago.

Upon examination, there is weakness in her left arm and leg (arm > leg) with decreased sensation. The patient becomes increasingly tearful and struggles to name objects around her, although she can describe their function. A systems review reveals a heart rate of 72/min and a blood pressure of 110/84 mmHg. There are no precordial murmurs or carotid bruits. An ECG shows that the patient is in sinus rhythm.

An urgent CT scan reveals an area of grey matter differentiation in the right hemisphere, leading to a diagnosis of Right Partial Anterior Circulation Syndrome (R PACS).

The patient has previously been taking amlodipine 5 mg and mirtazapine 30 mg once per day. She is started on aspirin. What other intervention should be considered for her treatment?

MRCP2-3016

A 75-year-old man with a history of hypertension and benign prostatic hypertrophy is brought in by ambulance after a fall. He reports feeling dizzy after standing up from his armchair, stumbled, and tripped over his cat. His wife, who witnessed the fall, reports that he then hit his head on the coffee table and lost consciousness for around 1 minute.

She describes no abnormal movements or incontinence. On regaining consciousness, he was immediately oriented. He remembers regaining consciousness. He has no headache, dizziness, nausea, or vomiting.

On examination, he has a small laceration on his forehead. His pupils were equal and reactive to light. He had no focal neurological deficits. He was a 15 on the Glasgow Coma Scale. His abbreviated mental test score was 10/10.

ECG: Sinus rhythm. 70 beats per minute. No T wave or ST segment changes.

Blood pressure (lying): 135/75 mmHg
Blood pressure (standing): 110/60 mmHg

Haemoglobin 135 g/dl
Troponin T 1 ng/L

Urine dip: trace of protein

What is the most appropriate course of action?

MRCP2-3017

A 25-year-old woman visited her doctor complaining of difficulty breathing during mild exertion. She reported a 7-year history of weakness in her limbs, preventing her from participating in sports during school. Her parents are first cousins and both are healthy, and she has two younger siblings without any medical issues. She denied experiencing muscle cramps or urine discoloration.

During the physical examination, weakness was noted in her shoulder and pelvic girdle muscles, as well as her trunk muscles. When taking deep breaths, her anterior abdominal muscles tended to retract. Tendon reflexes were reduced in all four limbs, but there were no sensory abnormalities.

What is the most probable diagnosis?

MRCP2-3018

A 55-year-old man presents with tingling in his left upper limb that originated in his neck and radiated down his left arm. He also experienced numbness and paraesthesia in his left lower limb. Upon examination, there was a restriction of neck movements and mild wasting in his left biceps. Inversion of the supinator and biceps jerks were noted, along with hyperreactive knee and ankle jerks and a positive extensor plantar response. A diagnosis of cord compression was made, and he underwent surgical decompression. However, post-surgery was complicated by septicaemia and urinary tract infection, and he remained bedridden for four days. Subsequently, he developed an inability to dorsiflex his right foot and right big toe, along with numbness on the outside of his foot and decreased eversion (but normal inversion). His reflexes remained unchanged. What is the cause of his postoperative weakness?

MRCP2-3019

A 35-year-old woman presents to the emergency department with severe, progressive abdominal pain over the past day. The pain is accompanied by nausea, vomiting and diarrhoea. The patient recalls similar episodes in the past that progressed over a few days and lasted for a week.

On examination: minimal abdominal tenderness and rebound tenderness. She has a history of abdominal surgery for suspected appendicitis and biliary disease, neither of which was confirmed once inside the abdomen.

What diagnostic test or procedure will help confirm the diagnosis?

MRCP2-3020

A 78-year-old man with a history of prostatic carcinoma presents to the Emergency Department with complaints of lower back pain and heavy legs with reduced sensation. On examination, he has percussion tenderness of his spine, loss of sensation up to the umbilicus, a distended bladder, and reduced anal tone. He also has significantly reduced power in his lower legs, hyperreflexia, and upgoing plantar responses. What is the most suitable investigation to request?

MRCP2-3021

A previously healthy 25-year-old man is brought to the Emergency department after a car accident. He has a GCS of 7 and is intubated and ventilated. A CT scan of his head reveals a large subdural hematoma on the right side. The decision is made to transfer him to a neurosurgical center 100 miles away. However, 70 miles into the transfer, he suddenly deteriorates and is diagnosed with a tension pneumothorax. What is the best initial course of action?

MRCP2-3022

A 50-year-old man arrives at the emergency department complaining of the most severe headache he has ever experienced. He explains that he was sitting with his wife when he suddenly felt excruciating pain at the back of his head. The pain quickly escalated to a 10/10 intensity, and he also feels nauseous, although he has not vomited yet.

The patient has a medical history of adult dominant polycystic kidney disease and hypertension, for which he takes ramipril. Upon examination, his Glasgow coma scale is 15/15, and there is no focal neurology.

Due to concerns of an intracranial bleed, a non-contrast CT head is ordered, which reveals hyperdensity in the subarachnoid space and ventricles.

What is the most appropriate definitive intervention for this diagnosis?

MRCP2-3023

A 65-year-old retiree presents to the clinic with complaints of foot pain and difficulty walking. Upon further questioning, the patient reports experiencing numbness in the soles of their feet for the past year, as well as a tingling sensation and burning pain. The patient also notes weakness in their legs and unsteadiness while walking, which has led to decreased mobility. The patient does not take any regular medications but has been purchasing over-the-counter painkillers for symptom relief. They have a history of smoking 1 pack of cigarettes per day for the past 40 years and report spending more time at home since retiring.

Physical examination reveals symmetrical distal sensory loss in the lower limbs and absent ankle reflexes even with reinforcement. There is no significant postural drop in blood pressure.

Which of the following is the most appropriate next step in management?

MRCP2-3024

A 25-year-old woman, who recently got married, visits the first seizure clinic and receives a diagnosis of idiopathic generalised epilepsy. She expresses her desire to start a family in the near future. Which first-line antiepileptic medication should be avoided?