Archives: MRCP Part 2

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?

MRCP2-3501

A 54-year-old woman presents to the medical admission unit with a severe headache that has been ongoing for the past five days. The headache is described as a constant dull pain across the front of her head, worsened by sitting up, coughing, or straining, and relieved only by lying down in a dark room. Paracetamol and ibuprofen have not provided any relief. She denies nausea or vomiting, and her vision is unaffected. Her past medical history includes non-classical migraines and hypothyroidism for which she takes levothyroxine. One week ago, she was admitted with a headache, fever, and photophobia. On examination, she is found lying flat in a dark room. Her vital signs are stable, and her neurological exam is unremarkable. What is the best next step in management?

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?

MRCP2-3509

A 47-year-old man has been referred to you by the Accident and Emergency doctors due to a severe headache. He reports that the headache woke him up at 3am and it is the most excruciating headache he has ever experienced. He has had two similar episodes over the past three days, each lasting approximately 70 minutes. The pain is concentrated around his left eye and temple and is described as sharp. Upon examination, you notice that his left eye is swollen and watering, and there is some redness and mild bruising above the eye. He admits to hitting his head against the fridge door in an attempt to alleviate the pain. What is your recommended treatment for his headache?