MRCP Part 2 Category: Neurology

MRCP2-3502

A 63-year-old man presents to the emergency department at 10:30 with left-sided arm and leg weakness and dysphasia. He noticed the symptoms upon waking up at 09:45. He had no symptoms before going to bed at 11:00 pm the previous night.

The patient lives alone and is fully independent, regularly driving to run errands. He is an ex-smoker and has a medical history of hypertension and carpal tunnel syndrome.

Upon arrival, the patient has a NIHSS score of 8 and a GCS score of 15. His cardiac monitor shows atrial fibrillation.

He is transferred to radiology for a CT angiogram with CT perfusion, which reveals evidence of an ischaemic stroke in the right distal anterior circulation. The perfusion imaging shows a small central area with markedly decreased cerebral blood flow, indicating a limited ischaemic core. In contrast, there is a large surrounding area with only moderately reduced cerebral blood flow and near-normal cerebral blood volume, suggestive of penumbra. There is mild cerebral oedema.

What is the appropriate course of management for this patient?

MRCP2-3503

A 65-year-old right-handed man presents to the Emergency department with sudden onset of left-sided facial weakness and numbness, along with a headache. He has a history of hypertension and is taking bendroflumethiazide. On examination, there is evidence of left facial asymmetry and pyramidal weakness of the left arm. The CT scan of the brain is normal, but the electrocardiogram shows atrial fibrillation. How should this patient be managed?

MRCP2-3504

A 32 year old man presents to the Emergency Department with a sudden and severe headache that reached a 10/10 severity within seconds of onset. He also reports a loud pulsatile pounding noise in his right ear. The patient denies any loss of consciousness or other neurological symptoms. Upon further questioning, he reveals that he was hit in the face with a soccer ball earlier that day.

The patient has no significant medical history and takes no medications. There is no family history of neurological disease. On examination, the patient’s right pupil is constricted compared to his left, with both pupils reactive to light. There is a partial ptosis of the right eye and possible right hypoglossal palsy. The remainder of the peripheral nervous system examination is unremarkable.

Initial investigations include a non-contrast CT brain, which shows no acute intracranial pathology or bony injury. A lumbar puncture reveals 2 red cells/mm³, 4 white cells/mm³, normal CSF glucose levels, and a CSF protein level of 0.65 g/L. The CSF gram stain is unremarkable and negative for hemoglobin breakdown products.

What is the most likely diagnosis for this patient?

MRCP2-3505

An 85 year old woman presents to the neurology clinic with increasing diplopia. She reports no speech or swallowing problems and no limb weakness. Her medical history includes chronic obstructive pulmonary disease and ischaemic heart disease. She is able to mobilise around her flat with a frame but requires a wheelchair outside the home due to exertional breathlessness. Regular medications include inhaled salbutamol and tiotropium, aspirin, simvastatin, bisoprolol and ramipril. The patient lives with her husband and has once daily carers to assist with activities of daily living.

During examination, ptosis is noted on prolonged upwards gaze, but there is no significant weakness of facial muscles, palate or tongue. There is no evidence of fatigable weakness in the arms or legs.

Further investigations reveal negative serum acetylcholine receptor antibodies and positive serum muscle specific tyrosine kinase. Neurophysiology shows no evidence of repetitive nerve stimulation. A CT thorax reveals a retrosternal soft-tissue density mass equal in attenuation to muscle, which demonstrates heterogeneous enhancement following contrast injection.

What is the appropriate management for the retrosternal mass?

MRCP2-3506

A 35-year-old woman presents with weakness in her left leg that has been ongoing for 2 days. On examination, she has a brisk ankle jerk and an upgoing plantar, with reduced power in dorsiflexion but normal tone. There are no abnormalities found in her right leg.

Upon further questioning, the patient reports experiencing numbness and tingling in her right hand 4 months ago.

What is the most effective treatment to reduce relapses for this patient, given the likely diagnosis?

MRCP2-3507

A 33-year-old male comes to the clinic complaining of shooting pain down both legs for the past week and a slightly weak right hand. He denies having any other significant neurological symptoms and has not been diagnosed with any chronic medical conditions.

Upon examination, the patient exhibits reduced fine motor control in his right hand and a brisk brachioradialis reflex on the right side. He also reports subjective sensory disturbance over his trunk, but there is no objective sensory loss.

Based on these findings, you suspect the patient may have multiple sclerosis (MS). What specific criteria must be met to diagnose relapsing remitting MS?

MRCP2-3508

A 49 year old female with relapsing-remitting multiple sclerosis (MS) reports an increase in fatigue, which has led to her having to quit her job as a medical secretary. Despite always maintaining a balanced diet, engaging in gentle exercise, and promptly treating infections, her symptoms have worsened. Upon review, she appears to be in good spirits. Her recent blood work is as follows:

– Hemoglobin: 120g/dl
– Platelets: 150 * 109/l
– White blood cells: 5.2 * 109/l

Her electrolyte levels are within normal range, with a sodium level of 130 mmol/l and a potassium level of 3.8 mmol/l. Her urea level is 6.0 mmol/l and her creatinine level is 68 µmol/l. Tests for B12, folate, and thyroid function are all normal.

What would be the most appropriate course of action?

MRCP2-3496

A 75-year-old male has two episodes of weakness affecting the right arm and leg each lasting ten minutes, both within the space of 2 days. He did not attend the emergency department after the first episode. His only significant past medical history is hypertension, for which he takes lisinopril 10 mg OD. He has experienced one similar episode to this one year ago but did not seek medical attention. His son is present who informs you that the patient has lost a significant amount of weight in the last year. On further questioning, he reports some haemoptysis lately. His blood pressure in the department was 160/90 mmHg initially.

His bloods reveal:

Hb 12.0 g/dl
Platelets 155 * 109/l
WBC 12.8 * 109/l

Na+ 135 mmol/l
K+ 4.9 mmol/l
Creatinine 98 µmol/l
CRP 12 mg/l

ECG: Sinus tachycardia, rate 100/min

What is the most appropriate management for this gentleman?

MRCP2-3497

A 63-year-old man, originally from India, presents to the rapid access chest clinic with a dry, irritating cough and a one-month history of weight loss (approximately 5 kg). He has also experienced loss of sensation in both feet and lower legs over the past two days. On examination, heart sounds 1 and 2 are present with no added sounds, and there is reduced air entry in the mid and lower left zones of the chest. The patient has a non-tender liver edge that extends 3 cm below the costal margin, and there is loss of sensation for pain, light touch, and temperature in both feet up to the mid-shin. A chest X-ray reveals a unilateral hilar mass, but no other consolidation or features. The patient has a past medical history of mild hypertension and diet-controlled diabetes mellitus, and he takes enalapril for his hypertension. Blood tests show no obvious abnormalities. What is the most likely diagnosis?

MRCP2-3498

A 65-year-old man went on a road trip with his family, and after arriving at their destination and settling in, his son noticed that he became confused suddenly, repeatedly asking where they were and how they got there. He could not remember events that occurred in the past 24 hours, and when told the answers to his questions, would ask the same question 5 minutes later. There was no change in his personality, no change in his speech, nor any muscle weakness. He is able to recall his address, the names of his sons and wife, and his date of birth.

His son said his father did not suffer any trauma during the road trip, and did not lose consciousness anytime throughout the day. The patient’s past medical history includes hypertension and diabetes, and he takes lisinopril 10 mg once daily, and metformin 500mg twice daily.

On examination the patient was alert, but constantly asked where he was and why was he there. He was afebrile, heart rate 76 bpm, blood pressure 142/72 mmHg, respiratory rate of 16 breaths per minute, and oxygen saturation of 98% on air. Neurological examination was unremarkable, but his abbreviated mental test score was 6/10.

His investigation results were as follow:

C Reactive protein 3 mg/l
Haemoglobin 13.9 g/dl
White cell count 6.2 x 10^9/L
Na+ 140 mmol/l
K+ 4.1 mmol/l
Urea 4.5 mmol/l
Creatinine 72 µmol/l
Corrected calcium 2.35 mmol/l
Plasma glucose 7.2 mmol/l

Computer Tomography (CT) head scan No acute intracranial pathology.

Over the next 12 hours, his memory improves and he is discharged from the observation ward.

What is the best advice for the patient with regards to driving in the future?