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?
MRCP2-3472
An 85-year-old male presents as a blue light ambulance call with a sudden onset inability to move his right side that has been ongoing for twelve hours. Upon examination, there is an expressive and receptive dysphasia accompanied by a dense right sensorimotor syndrome. The cardiovascular examination is unremarkable except for an irregular heartbeat at 80 per minute. A hyperacute CT head reveals a large area of ischaemia in the left middle cerebral artery vascular territory. The patient is not eligible for thrombolysis and is started on 300mg aspirin. A subsequent echocardiogram shows a 60% ejection fraction with no mural thrombus, while a carotid Doppler reveals 40% left and 35% right stenosis. A 24-hour tape demonstrates new atrial fibrillation. What measures can be taken to reduce the risk of future strokes?
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?
MRCP2-3478
A 15-year-old comes to your neurology clinic complaining of progressive weakness in his lower limbs that has been gradually developing for the past 10 months. He has noticed difficulty keeping up with his peers during physical education classes for the past year and a half, which he initially attributed to his lack of athleticism. However, he now experiences weakness when walking and has particular difficulty rising from a seated position.
During the examination, you observe significantly enlarged calf muscles. Formal power testing reveals 4- out of 5 in bilateral shoulder abduction and adduction, with normal 5 out of 5 distally. Additionally, 4- out of 5 is noted in hip flexion and extension, 4+ in knee flexion and extension, and 5 out of 5 in ankle plantar and dorsiflexion. The weakness is not fatigable and is persistent. Reflexes are present in all areas, and plantar reflexes are downgoing. The patient has no significant medical history, and his family history is unknown as he was adopted. What is the most likely diagnosis?
MRCP2-3460
A 38-year-old Japanese female presents with her second episode of loss of colour vision and significant visual acuity impairment in both eyes. Three days later, she complains of vomiting, acute urinary retention, requiring urinary catheter insertion, and inability to move either leg. On examination, she was unable to correctly name any Ishihara plates. An MRI of her brain and spine demonstrates multiple hyperintense T2 white matter lesions in her spine suggestive of demyelination, one of which extends from C5 to T1. What test confirms the diagnosis?
MRCP2-3461
A 32-year-old woman has presented to the Emergency Department (ED) with suspected disc prolapse. She visited her GP with stiffness and weakness in both lower limbs, which developed over the last 24 hours. She has started to develop difficulty passing urine over the last 6 hours. She has no other medical history. When seen in ED, she is is able to walk, although she has a stiff-legged gait. Tone is increased in both legs. Power is 4±5 with pathologically brisk reflexes and sustained beats of clonus at both ankles. The plantars are up-going bilaterally. There is decreased soft touch sensation until a level around the umbilicus. There are no neurological abnormalities in the arms. The cranial nerve examination is also normal. The orthopaedic registrar reviewed the patient earlier in the day and requested urgent magnetic resonance imaging (MRI) of the lumbar spine. This was reviewed by the radiologist and was reported as showing no structural lesions. The scan shows from the T9 vertebrae down to the sacral area. The orthopaedic registrar feels that this is not a surgical problem and wonders whether it might be multiple sclerosis. They ask you, the medical registrar, what you would like to do with the patient. You examine the patient and agree with the physical signs. What is your plan of action?