Archives: MRCP Part 2

MRCP2-3450

A 35-year-old teacher with controlled hypertension complains of increasing weakness and fatigue, particularly in the afternoons. She has noticed occasional double vision and her colleagues have commented that her eyelids appear droopy at times. Her symptoms seem to worsen as the day goes on. She reports being a non-smoker and drinking alcohol only occasionally.
On examination, there is mild ptosis of the right eye. After sustained upward gaze for 30 seconds, there is complete ptosis of the right eye and partial ptosis of the left eye. There is no diplopia in the primary position. Eye movement examination reveals incomplete abduction of both eyes, with variable diplopia on horizontal and vertical pursuit. Limb examination shows generalized weakness, which is more pronounced proximally. Reflexes are symmetrical with flexor plantar responses. There is no sensory loss.
Which diagnostic investigation would be most helpful in this case?

MRCP2-3451

A 64-year-old man presents to the Elderly Care Clinic for review after retiring due to being unable to cope with the pace of his job. His wife is concerned about his increasing withdrawal, apathy, and mobility problems, including three falls at home and incontinence of urine. He has a past medical history of hypertension and an inferior myocardial infarction. On examination, he has a flat affect, unsteady gait, small shuffling steps, a minor tremor, increased muscle rigidity, and paralysis of upward gaze. His blood pressure is 145/72 mmHg, and pulse 85 bpm with a 20 mmHg postural drop on standing. Investigations reveal normal values for haemoglobin, white cell count, platelets, sodium, potassium, creatinine, glucose, and thyroid-stimulating hormone. Chest X-ray and computed tomography head are unremarkable. What is the most likely diagnosis?

MRCP2-3452

A 50-year-old male is discovered confused on the street by a police officer. Medical records indicate that he is a known type 2 diabetic with a history of non-attendance to clinic and poor adherence to medications. He has also been admitted to the hospital twice before, 2 and 10 years ago, for alcohol withdrawal. During the examination, the patient is disoriented in time and place, scoring 0 out of 10 on the abbreviated mental test. He is able to comply with commands to lift his upper and lower limbs during his neurological examination, and all reflexes are present. However, he fails to track your finger with his eyes during the cranial nerve examination. His gait is significantly ataxic, as evidenced by his attempt to walk to the bathroom against medical and nursing advice. His blood sugar level is currently pending. What is the diagnosis?

MRCP2-3453

A 33 year old man presents with left lower limb weakness for the past four weeks. Over the past week his condition has deteriorated significantly. He has also experienced a loss of appetite and has lost six kilograms in the last two months. Additionally, he has reported recurrent nosebleeds during this time.

Despite using nicotine transdermal patches and varenicline for three months, he is now no longer actively smoking. He is married and works as a salesman for a pharmaceutical company. In the past year, he has traveled to many destinations around the world as part of his job.

During examination, he appeared unwell and was mentally slow in understanding commands. The power in his left leg was grade 2 for all muscle groups, while tone, sensation, coordination, and reflexes were all normal. No abnormalities were detected in other systems. The following investigations were ordered:

– Hb: 10g/dl
– Platelets: 10 * 10^9/l
– WBC: 4* 10^9/l
– Neutrophils: 60%
– Lymphocytes: 34%
– Na+: 135 mmol/l
– K+: 4 mmol/l
– Creatinine: 95 µmol/l
– Urea: 4 mmol/l

Urine analysis: Clear

An MRI of his brain showed bilateral multiple hyperintense demyelinating lesions involving subcortical areas without any mass effect.

What is the most appropriate course of action?

MRCP2-3454

A 44 year-old man is brought to the hospital after being found wandering aimlessly, unable to recall his identity or how he ended up there. Following a collateral history, he is referred to the neurologists for further evaluation.

Over the past few months, he has been experiencing increasing forgetfulness and clumsiness, along with progressively odd behavior. His speech has become muddled, and he struggles with everyday tasks. Others have observed that he has become quite fidgety, and he sometimes drops things unintentionally.

Previously, he was healthy and served as the primary caregiver for his father, who has motor neuron disease. His sister, who previously assisted him in caring for their father, recently died in a car accident.

At the age of 20, he underwent extensive surgical resection of a large parafalcine meningioma that was discovered after a chronic headache investigation. Since the operation, he has been free of headaches.

During the examination, he is entirely disoriented in terms of time, place, and person. His gait is broad-based and uncoordinated, and you observe several shock-like jerks of his arms. Tone, power, reflexes, and sensation are otherwise normal, and cranial nerve examination is unremarkable.

What is the most probable diagnosis?

MRCP2-3456

A 45-year-old secretary presents to the Outpatient Clinic with complaints of sharp, burning sensations over the right side of his face. He experiences episodes that last from a few seconds to approximately 2 minutes and occur up to 50 times a day with no symptoms in between. The pain is exacerbated by eating, speaking, and washing his face. A thorough neurological examination reveals no cranial nerve or limb signs, intact corneal reflex on both sides, and intact sensation on both sides of the face. The following investigations were conducted: Haemoglobin (Hb), White cell count (WCC), Platelets (PLT), Sodium (Na+), Potassium (K+), Creatinine (Cr), Mean corpuscular volume (MCV), Urea, Corrected calcium (Ca2+), Thyroid-stimulating hormone (TSH), T4, Vitamin B12, Folate, and Glucose. The results showed that the patient’s Hb, MCV, and Vitamin B12 levels were low. Which of the following treatments is likely to be of most benefit?

MRCP2-3457

A 45-year-old man presents to the Emergency Department with a 2-week history of increasing drowsiness and confusion. According to his wife, he had been complaining of fatigue and had been spending most of his time in bed for the past week. He stopped going to work a week ago. This morning, his wife had difficulty waking him up, and when she did, he seemed confused and had slurred speech.

The patient has a history of epilepsy and bipolar disorder. On examination, he only responds to painful stimuli. His vital signs are normal, and his chest and abdomen exams are unremarkable. Blood tests reveal:

Hb 152 g/l Na+ 139 mmol/l Bilirubin 18 µmol/l
Platelets 278 * 109/l K+ 4.3 mmol/l ALP 117 u/l
WBC 8.1 * 109/l Urea 5.2 mmol/l ALT 19 u/l
Neuts 5.4 * 109/l Creatinine 93 µmol/l γGT 48 u/l
Lymphs 1.8 * 109/l Albumin 41 g/l
Eosin 0.2 * 109/l Ammonia 197 µmol/l

The patient’s wife mentions that his medications were recently changed by his GP. What medication change is most likely responsible for his symptoms?

MRCP2-3458

A 42-year-old woman is referred by her primary care physician to the Neurology Clinic. She has a 3-year history of involuntary movements in her hands associated with weight loss. Her husband describes these as ‘piano playing’. More recently she has been emotionally labile with aggressive outbursts and has begun to have some memory problems. She has a family history of ‘Parkinson’s disease’, which affected her maternal grandmother in later life and affects a maternal uncle. Her own mother died in her early thirties in an accident.

Upon examination, she has hypometric saccadic eye movements with broken pursuit movements and some nystagmus at the extremes of gaze. She has continuous fidgety movements of her fingers and arms. There is extrapyramidal rigidity in all four limbs with a shuffling gait. ‘Bedside’ higher function testing reveals some disinhibition with irritability and impaired episodic memory.

Magnetic resonance imaging (MRI) of the brain reveals no significant abnormalities beside some possible cerebral atrophy. Electroencephalogram (EEG) is non-specifically abnormal. Cerebrospinal fluid (CSF) analysis reveals an acellular fluid:

Glucose 4.2 mmol/l (serum 6.8 mmol/l) 2.5–3.9 mmol/l
(two-thirds plasma value)
Protein 0.50 g/dl < 0.45 g/l
14-3-3 protein Negative
S100b Normal range

Choose the test most likely to confirm the 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?