A 55-year-old unemployed man presented with a 7-month history of progressive speech difficulty. He had appeared depressed over the same period after losing two jobs in the last year. His wife commented that he had lost all motivation and spent most of the day at home. His appetite had changed and he had become very fond of sweet foods, with his weight increasing by 2 stones in the last year. Higher mental function testing revealed problems with naming and in tasks requiring planning.
Examination of the cranial nerves and limbs was normal.
What is the most likely diagnosis?
MRCP2-3540
A 32-year-old man presents to the Psychiatry Hospital with a 4-month history of insomnia, weight loss, depression, forgetfulness, and pins-and-needles sensation in his limbs. He was prescribed amitriptyline, but after 8 weeks, he began experiencing increased forgetfulness, unsteadiness, and intermittent incontinence. A medical registrar was consulted and found the patient disorientated to place and person, with myoclonic jerks, restricted upward gaze, limb and gait ataxia, and flexor plantar reflexes. A CT scan of the head was normal, but an EEG showed diffuse slowing. Further investigations revealed a positive anti-thyroid peroxidase antibody and elevated TSH levels. What is the most likely diagnosis?
MRCP2-3525
A 35-year-old man visits his primary care physician with complaints of intense pain in his right ear for the past three days. He also reports experiencing drooping of the right side of his face for the past 24 hours.
Upon examination, his blood pressure is 122/80 mmHg and his heart rate is 80 bpm. Neurological examination does not reveal any weakness in his limbs. He has drooping of the right side of his face and is unable to close his right eye or raise his right eyebrow. Local examination of his right ear shows vesicular lesions on an erythematous base in his external ear canal.
What is the most appropriate course of action for managing this patient?
MRCP2-3510
A 35 year old male Intravenous drug user presents to genito-urinary clinic. He was diagnosed with HIV 2 years ago after presenting with tuberculosis (TB). He was treated for TB for 6 months. He is now on third line anti-retroviral therapy for previous virological failure and co-trimoxazole. His most recent CD4 count was 110, and his viral load was 2,500 copies/ml.
He complains of weakness on his right side, and deterioration in hearing, getting worse for three weeks. He has a severe headache. On examination his hearing is reduced in his right ear and normal in his left ear. He has weakness, in his right arm and leg, brisk reflexes and mildly increased tone.
He is immediately admitted.
A CT scan shows several ring enhancing lesions in his left cerebral hemisphere and one on the right cerebral hemisphere.
On audiological review he has a large area of cochlear necrosis in his right ear.
What is the diagnosis?
MRCP2-3511
A 72-year-old man accompanied by his son was seen in general clinic with episodes of disorientation. His son had witnessed several of these episodes whereby one minute he could be having a conversation and then next minute he would start asking ‘where am I?’ He would keep asking this question, but seemed fully aware of his surroundings, and was able to perform tasks in the house and otherwise seemed fairly attentive. These episodes could go on for several hours. His son was particularly concerned as these episodes seemed to post date the loss of his wife from cancer and he was aware that his father had taken to drinking a moderate amount of alcohol. He had not lost any weight or complained of poor appetite or disturbed sleep.
He had a past medical history of hypertension and arthritis and took regular bendroflumethiazide and Arthrotec. He was a non-smoker and drank approximately 15 units of alcohol per week.
On examination he seemed fully aware of his surroundings but appeared disorientated in time and place and kept asking ‘where am I?’ When the physician explained he was in hospital he acknowledged the answer, but within minutes was asking the same question. This continued throughout the consultation.
He was able to comply with physical examination which did not reveal any abnormalities within the cranial nerves or peripheral nervous system. General, cardiovascular and abdominal examinations were all normal.
Investigations revealed:
Full blood count Normal – Biochemistry Normal – Thyroxine 59 nmol/L (58-174) Thyroid stimulating hormone 6.9 U/L (<7)
An MRI scan of the brain showed mild generalised cerebral atrophy.
What is the most likely diagnosis?
MRCP2-3512
A 50-year-old woman is brought to the Emergency department at 7 pm by her daughter who claims that she has become confused and is acting strangely. The patient insists that she feels fine and does not understand why she was brought to the hospital.
Upon further questioning, the patient reports that she had arrived home at 3 pm and went to sleep. Her daughter, however, describes finding her mother wandering around the house and not recognizing her own husband. The daughter is very concerned that her mother had to be reminded repeatedly that they were at the hospital.
The patient has no significant medical or surgical history and was previously healthy until this afternoon when she had a normal day working as a teacher.
On examination, there are no neurological deficits and fundoscopy is normal. Notably, the patient is cooperative but appears surprisingly calm and unconcerned about her condition.
What is the most appropriate course of action for managing this patient’s condition?
MRCP2-3513
A 55-year-old man with a history of heavy alcohol consumption presents with three episodes of generalised convulsive seizures within two hours. He claims to have abstained from alcohol for the past two days and has no other significant medical history. A CT scan of the brain shows no abnormalities. In the event of another seizure, what is the most suitable treatment for this patient?
MRCP2-3514
A 70-year-old man presents to the clinic after experiencing three episodes of transient right monocular visual loss. He describes the visual loss as a curtain descending down on the right eye, lasting several minutes and resolving. He also reports recent headaches. He denies any limb weakness and has been in good health prior to these events.
The patient has a medical history of hypertension and takes regular bendroflumethiazide. He is a heavy smoker, consuming 30 cigarettes per day, and does not drink alcohol. On examination, he appears plethoric with a blood pressure of 140/80 mmHg, pulse of 88 beats per minute and regular rhythm. Oxygen saturation is 99% on room air.
An audible bruit is heard over the right carotid artery, and he has pulsatile non-tender temporal arteries. A mass is palpated in the left upper quadrant of his abdomen. His heart sounds are normal, and his chest is clear. A full neurological examination, including fundoscopy, is entirely normal.
Investigations reveal a high haemoglobin level, elevated white cell count and platelets, and increased haematocrit and red cell count. Doppler scanning of the carotid arteries shows 100% stenosis of the left internal carotid artery and 60% stenosis of the right internal carotid artery. He is started on aspirin 300 mg orally for two weeks.
What further actions would you take for this patient?
MRCP2-3515
A 35-year-old man comes to the Neurology Clinic for evaluation. He has been experiencing severe headaches every afternoon and evening, which are located in the frontal, like a band around his head and last for 1-2 hours each time. He has been taking 2g of Acetaminophen and 30 mg of Codeine phosphate four times a day, and has attempted to stop taking the medication, but the headaches return when he does. His neurological examination is normal, and his CT and MRI scans, as well as a variety of screening blood tests, have all come back normal. What is the most appropriate next step?
MRCP2-3516
A 72-year-old male presents with visual loss.
During examination, it is found that his blood pressure is 168/102 mmHg and fundoscopy reveals an embolus to the right superior temporal branch of the retinal artery. Carotid dopplers are arranged and show normal left-sided carotids, but a 90% stenosis in the right external carotid artery and approximately 70% stenosis in the right internal carotid artery.
What is the most appropriate treatment for this patient?