Archives: MRCP Part 2

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?

MRCP2-3499

A 56-year-old female presents to the hospital with recurrent falls and cognitive decline over the past 8 weeks. Her husband reports a possible cough and cold about 3 months ago, but otherwise, she has no significant medical history. On examination, she appears easily startled and has bilateral finger-nose and heel-shin dysmetria, mild postural tremor, and mild speech slurring. Blood tests and a lumbar puncture were performed, with results showing elevated TSH levels and a positive 14-3-3 protein. An EEG demonstrated periodic spikes, and an MRI showed no parenchymal abnormalities. What is the most likely diagnosis?

MRCP2-3500

A 30-year-old woman presents to the neurology clinic with a worsening headache that has been ongoing for a month. The headache is mostly frontal but sometimes moves to the back of her head. It is throbbing in nature and is worst in the morning. She has also been experiencing a thudding sound in her ears. She has no change in vision or photophobia, but the headache has started to make her feel sick. She has no significant medical history and is only taking oral contraceptives. She is obese, a non-drinker, and smokes ten cigarettes per day. On examination, her blood pressure is 165/94 mmHg, and her heart rate is 90/min. Her pupils are equal and reactive, and her visual fields are full to confrontation. Fundoscopy reveals slight blurring of the optic disc margins with a normal retina. The examination of the other cranial nerves reveals no deficits, and her limbs’ tone, power, coordination, and reflexes are all normal. Her BMI is 31, and her blood tests are within normal limits. What is the most appropriate imaging investigation to perform next?

MRCP2-3482

A 67-year-old male presents to the neurology outpatient department with a history of recurrent bouts of unsteadiness and vomiting over the last 10 years, with partial resolution. He has also had episodes of visual problems, which he describes as the sudden loss of vision in the right eye, with an almost complete recovery of vision over the course of the next few weeks. He has a history of type 2 diabetes and is hypertensive and is generally non-compliant with his treatment. He is also a smoker with a 50 pack year history.

His medication includes glimepiride 2mg daily and metformin 500mg TDS. He also takes telmisartan 40 mg daily.

On examination, he has nystagmus in the right eye with the fast component towards the right. His gait is ataxic and he has evidence of spasticity in both lower limbs with exaggerated reflexes and bilateral ankle clonus. Fundoscopic examination revealed a pale optic disc.

MRI brain shows diffuse lesions in multiple sites. The report queried demyelinating plaques vs multiple infarcts.

What would be the most appropriate next investigation for this 67-year-old male?

MRCP2-3483

A 25-year-old female presents with a constant diffuse headache, worse on standing than lying down, without neck stiffness or photophobia, but associated with nausea and vomiting. She was recently discharged from the neurology team after being investigated for intermittent headaches over the past 8 months. During her admission, she experienced up to 5 episodes a week, with one episode witnessed by the senior house officer. Her blood tests were unremarkable, and a CT head showed no intracranial lesions. A lumbar puncture was performed, and the patient self-discharged with no immediate complications. However, during this second admission, an MRI head scan revealed significant diffuse meningeal enhancement and bilateral shallow subdural haemorrhages. What is the appropriate treatment for this 25-year-old female?

MRCP2-3484

A 35-year-old man is brought to the Emergency Department after being seriously assaulted. Upon arrival, his GCS is 5/15 and he is intubated before being transferred for a CT head (with contrast). Based on the image provided, which blood vessel(s) is/are most likely to have ruptured?

MRCP2-3485

A 59 year old man arrives at the Emergency Room with his wife, expressing concern about his memory. He first noticed a problem when he struggled to prepare breakfast in the morning. When questioned, he cannot recall today’s events and has only fragmented memories of the past week, although his wife confirms that he had no memory issues yesterday. He seems highly anxious about his memory loss and repeatedly asks, Do I have dementia?

MRCP2-3494

You review an 85-year old retired teacher in your clinic who has been experiencing numbness in her arms and difficulty walking. Upon examination, you observe reduced sensation on the lateral aspect of her arms and forearms in the anatomical position. There is no muscle wasting on her hands, but she has reduced biceps and supinator reflexes and reduced power bilaterally. Additionally, she has a wide-based scissoring gait and is unable to stand still without support when asked to close her eyes.

This patient lives independently but has been struggling to cope recently. She has a history of hypertension and high cholesterol. What investigation would be most appropriate to diagnose her condition?