A 35-year-old man underwent surgical removal of a compressive pituitary macroadenoma in France four weeks ago and has been receiving pituitary hormone replacement therapy since, including growth hormone. The surgery was uncomplicated, and he initially had a smooth recovery. He has no other medical history. However, he has recently developed poor balance with a broad-based gait and severe forgetfulness over the past one to two weeks. During the examination, you notice an ataxic gain and occasional myoclonic limb movements. His MMSE score is 22/30, and routine blood tests are normal. Based on the probable diagnosis, what abnormalities might you expect to see on his brain MRI?
MRCP2-3026
A 24-year-old male presents to the emergency department with a sudden onset headache. The nursing staff are concerned about the appearance of his ECG taken at triage. He denies any chest pain or shortness of breath. On examination, he appears agitated and refuses to open his eyes to light. His blood pressure is 140/80 mmHg and his heart sounds are normal. There is no visible JVP and his lung fields are clear.
What is the most probable reason for the ECG changes observed in leads V4-V6?
MRCP2-3027
A 67-year-old woman presented to her GP with sudden onset of visual disturbance in her right eye accompanied by a throbbing headache on the right side of her head. She described the visual disturbance as a moving silhouette descending from above leading to complete visual loss, which lasted for about a minute and then resolved. She also complained of pain in her jaw while chewing food and when combing her hair. This had occurred several times in the past week. The patient had a medical history of hypertension and polymyalgia rheumatica and was taking bendroflumethiazide 2.5 mg/day.
On examination, the patient was alert and oriented. Her blood pressure was 140/75 mmHg, and her pulse was 76/min and regular. She had an ejection systolic murmur radiating into the neck and no carotid bruits on cardiovascular examination. Fundoscopy examination revealed bilateral silver wiring and AV nipping. The right temporal/jaw area appeared tender and pulsatile. Peripheral nervous system examination was normal.
Investigations showed that the patient had a low haemoglobin level, high platelet count, and high ESR (Westergren). Carotid Dopplers revealed that the left internal carotid artery had 100% stenosis, while the right internal carotid artery had less than 50% stenosis. The patient’s cholesterol level was high, and her other blood test results were within normal limits.
What is the likely diagnosis for this patient?
MRCP2-3028
A 70-year-old man is brought to the emergency department after a fall. His daughter found him unresponsive on the floor after hearing a loud noise. The patient’s daughter reports that he has been unsteady on his feet for the past few days and is recovering from a urinary tract infection. The patient has a medical history of benign prostatic hyperplasia and atrial fibrillation, for which he takes tamsulosin, finasteride, and rivaroxaban.
Upon examination, the patient is drowsy with a GCS of 12 (E3V4M5). His heart rate is 85 bpm, and his blood pressure is 210/118 mmHg. His chest is clear with normal heart sounds upon auscultation. Oxygen saturations are 90% on air. The patient has a deep laceration over the left side of his forehead, which is oozing blood, and there is bruising down the left side of his body. Pupils are equal and reactive to light.
A CT scan of the head reveals evidence of a moderate intracranial hemorrhage in the left frontal lobe, with no evidence of a mass effect.
What is the most appropriate next step in managing this patient?
MRCP2-3013
A 27-year-old man presents to the emergency department with a sudden occipital headache that quickly became severe and was accompanied by vomiting. He has no regular medication use or history of recreational substance use. He has been referred to the genetics clinic due to a family history of phaeochromocytoma and kidney tumors. On arrival, he has a decreased Glasgow Coma Scale, reactive pupils, and a rigid neck. His blood pressure is elevated, and he has two cafe-au-lait spots on his trunk. Urine dip shows blood and positive leukocytes, and an ECG shows ST elevation in V1-V4. A CT scan reveals a large high attenuation signal in the left cerebellar hemisphere with surrounding edema and no mass effect. A lumbar puncture shows xanthochromia color and raised red cells. What is the likely unifying diagnosis?
MRCP2-3001
A 23-year-old female presents to a neurologist with involuntary movements affecting her arms and legs, described as a ‘shock wave’. She reports these movements occurring frequently throughout the day but not causing pain. Additionally, she has experienced cognitive decline and poor memory. The patient has a history of tonic-clonic seizures and was recently diagnosed with impaired glucose tolerance, for which she takes carbamazepine. There is a family history of early onset dementia on her mother’s side. On examination, the patient appears to have slow mentation and exhibits impaired recall. Fundoscopy reveals bilateral optic atrophy, and there is some slight weakness of shoulder abduction. Investigations show normal serum electrolytes and renal function, with a slightly elevated serum carbamazepine level within the therapeutic range. A lumbar puncture reveals elevated CSF opening pressure and lactate, with normal protein and white cell count. EEG shows generalised slow waves, and MRI brain scan is normal. Based on these findings, what is the likely diagnosis for this patient?
MRCP2-3002
A 43-year-old widow presents with a one week history of progressive confusion and unsteady gait. She works as a waitress and lives in poor social circumstances.
On examination, she is malnourished and disorientated. She has nystagmus and is unable to abduct either eye. The pupils are sluggish and unequal. Ankle jerks are absent but upper limb reflexes are present.
Shortly after her admission, you are called to the ward as she has become very drowsy and has collapsed on the floor.
What is the most likely cause of her presentation and drowsiness based on the following admission investigations?
A 75-year-old man who is a chronic alcoholic is brought to the Emergency Department by an ambulance. He was found collapsed in the street. On admission his airway, breathing and circulation are satisfactory. His GCS is 13/15 (eyes = 3, verbal = 4, movement = 6) although his level of consciousness appears to be fluctuating. There are no obvious signs of external head injury.
A CT head (without contrast) is performed:
What is the most probable diagnosis?
MRCP2-3004
A 45-year-old woman presents with wasting and weakness that initially affected her lower limbs and has now spread to her upper limbs. She experiences unsteadiness and clumsiness, particularly in the dark, and has numbness in her feet. These symptoms have been slowly progressing over the past decade. She reports no bladder issues and has no contact with her father, who reportedly had similar symptoms but to a lesser degree. On examination, her tone is flaccid, and there is weakness in the distal muscles of her legs, particularly in dorsiflexion and eversion of the ankles. There is also mild weakness in her arms, absent tendon reflexes, and mild blunting to pinprick over her feet bilaterally. Her cranial nerve examination is unremarkable. What is the most crucial step in investigating this patient’s condition?
MRCP2-3005
A 43-year-old man presents with a fever. He reports that it started a few days ago and he has developed a frontal, dull headache. He usually stays healthy but had a fever and joint pain a few weeks ago. During the examination, nuchal rigidity and sensory loss in the right ulnar nerve distribution were noted. Blood tests showed elevated WBC and CRP levels, while CSF analysis revealed lymphocytic pleocytosis and elevated protein levels. An ECG showed first-degree heart block. What is the most likely causative agent for this patient’s symptoms?