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?
MRCP2-3495
As the medical registrar on-call, you receive a fast-bleep to attend to a patient in the resuscitation room of the Emergency Department. A 28-year-old woman has been admitted with severe breathing difficulties and hypoxia, and has become increasingly drowsy during her time in the department. The emergency physicians have performed arterial blood gases, which show:
Due to the rapidity of her decline, the emergency physicians were only able to obtain a brief history before intubation was required. The patient reported a productive cough over the last few days and mentioned that she was taking tablets for a neurological condition.
Upon examination, you notice that the patient is intubated and maintained on sedation with propofol. She has a well-healed midline sternotomy scar, and coarse crackles are audible in the left mid and lower zones of her chest.
The patient is transferred to the Intensive Care Unit for continued mechanical ventilation and is started on empirical broad-spectrum antibiotics. What additional intervention would most hasten her recovery?
MRCP2-3468
A 79-year-old male presents to the hyperacute stroke unit with a sudden onset left sided hemiparesis and which is subsequently demonstrated to represent an acute ischaemic infarct in the right middle cerebral artery territory with no haemorrhagic transformation. He was not thrombolysed due to presentation being outside the time window.
As part of his stroke investigations, echocardiogram demonstrates no mural thrombus or regional wall abnormalities and an ejection fraction of 70%. The 24 hour tape recorded no arrhythmias. Carotid Dopplers demonstrate 40% stenosis in the right internal carotid artery, 55% stenosis in the left internal carotid artery. Blood pressure measured 125/75 mmHg.
He takes simvastatin 40 mg nocte and has no known drug allergies. What would be the optimal treatment?
MRCP2-3470
A 70-year-old male with a history of ischaemic heart disease and currently taking aspirin presents with a recent TIA causing brief right sided weakness. There is no known atrial fibrillation and routine telemetry has not detected any.
The MRI brain scan shows no evidence of acute stroke and the transthoracic echocardiogram does not reveal any intra-cardiac thrombus. However, a carotid ultrasound study reveals a 70-80% stenosis of the left internal carotid artery.
In addition to ordering a CT carotid angiogram to further investigate the lesion, what would be the next best step in managing this patient?
MRCP2-3471
A 67-year-old man presents with weakness that started 3 hours ago. He reports weakness in his right arm and leg, as well as difficulty finding words. His medical history includes hypertension and hypercholesterolemia. Upon examination, he has grade 4 weakness in his right arm and leg, a right-sided facial droop, and a right homonymous hemianopia. While he can follow complex 3 stage commands, he struggles to name simple objects. You suspect an acute stroke and are considering thrombolysis. You order blood tests and an urgent CT scan. What scoring system will you use to further evaluate this patient?
MRCP2-3473
A 75-year-old patient presents with complaints of severe headaches and lethargy for the past 3 weeks. The patient has a medical history of atrial fibrillation and is currently taking warfarin. A CT head (with contrast) is conducted:
What is the probable diagnosis?
MRCP2-3474
A 49-year-old woman presents to the emergency department with a severe headache that started earlier that day while she was walking around her office. The pain was felt across her entire head and was much improved when she lay down flat. There were no associated symptoms and the patient had been feeling well in the preceding days. She has no past medical history and is nulliparous. She is a non-smoker who consumes 15 units of alcohol per week.
On clinical examination, there is no evidence of focal neurological deficit or meningism. Simple analgesia given in the emergency department had limited impact on the patient’s headache. CT brain with venogram showed no evidence of intra-axial or extra-axial bleeding, space-occupying lesion, hydrocephalus, or venous sinus thrombosis. Lumbar puncture revealed an opening pressure of 5 mmHg, red cells 8 mm³, white cells 1 / mm³, and no xanthochromia.
What is the most appropriate next investigation to confirm the likely diagnosis?
MRCP2-3475
A 28 year old female has been referred for a neurological consultation. She reports experiencing two instances of unilateral blurred vision loss in the past six months. Her symptoms developed gradually over a few days and included vision blurring and pain, especially when moving her eyes. On both occasions, her symptoms peaked within three days and then gradually resolved over a two week period. Lumbar puncture results show an elevated protein level and CSF pleocytosis. Additionally, her serum Aquaporin-4 test is positive. What is the most probable diagnosis?
MRCP2-3476
An 86-year-old man was urgently referred by his General Practitioner to the stroke team for an outpatient assessment following a concerning episode reported by his care staff. The patient had a history of mild dementia but was mostly independent with daily activities and only required minimal assistance from his caregivers. However, he was found to be unusually drowsy and unresponsive in his armchair one week prior, with difficulty following commands and weakness in his left arm and leg. Although the symptoms resolved within 30 minutes, the patient remained confused and had reduced mobility. Upon further questioning, it was revealed that he had also fallen a few days prior to the episode.
The patient’s medical history included myocardial infarction, atrial fibrillation, and mild dementia. He was taking aspirin, ramipril, bisoprolol, simvastatin, and warfarin, which had been well-controlled with no recent fluctuations in his INR levels. He did not drink and was a former smoker. Despite his cognitive impairment, there was no evidence of dysphasia during examination, and his pupils were equal and reactive to light. However, he did have an irregular pulse and a left plantar response.
Based on the results of investigations performed during his clinic assessment, including an electrocardiogram, chest x-ray, carotid doppler, and transthoracic echocardiogram, what is the most likely finding on his subsequent CT brain scan?
MRCP2-3477
A 60-year-old Afro-Caribbean female presents to the Emergency Department with a 4-day history of unusual behavior at home. Her family had noticed that she was very disinhibited and agitated during a dinner party they hosted. She also reported experiencing hallucinations. Over the past 3 weeks, she has had two episodes of generalised seizures lasting up to 5 minutes each, with associated urinary incontinence and tongue biting. She has no history of epilepsy and is not taking any regular medications, but was diagnosed with ovarian teratoma two years ago. On examination, she has no focal neurology but exhibits a dystonic orofacial movement disorder. A CT scan of her head was unremarkable, with no acute infarct, haemorrhage or space occupying lesion demonstrated.
What investigation is the most appropriate for making a diagnosis?