Archives: MRCP Part 2

MRCP2-3459

A 75-year-old male presents to the neurology outpatient department with a history of left-sided body weakness that lasted for 30 minutes and resolved completely. He experienced numbness and tingling in the affected area and remained conscious throughout the episode. The patient has a history of hypertension, hypercholesterolemia, smoking, and heavy drinking. He also reports a tremor in both hands that improves after drinking and unsteadiness while walking.

During examination, the patient’s blood pressure is 150/95 mmHg, and a carotid bruit is audible over both sides of the neck. Neurological examination reveals impaired sensations in a glove and stocking distribution. Investigations reveal deep S waves in lead V1-V3 and tall R waves in V4-V6 on ECG and an enlarged cardiac silhouette with flecks of calcification around the aorta on CXR. Carotid artery Doppler studies reveal 85% occlusion in the right external carotid, 50% occlusion in the right internal carotid, 80% occlusion in the left internal carotid, and 60% occlusion in the left external carotid artery.

What is the most appropriate treatment option for this patient?

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?

MRCP2-3462

A 33 year-old teacher presents to the neurology clinic.

For the past year, she has been experiencing severe headaches. These headaches usually occur in the morning and sometimes wake her up from sleep. The pain is sudden and stabbing, located behind her right eye. During the attacks, she feels the need to pace around the room and pound her head to ease the pain. Her right eye becomes watery and her nose congested. She has also noticed that her left pupil appears enlarged during the attacks. The pain is so severe that she has considered jumping out of the top floor of the school building where she works. Each attack lasts for one to two hours, and she feels fine between the attacks.

She has been keeping a detailed headache diary, which shows that she had a period of nine days in January with several attacks daily, followed by a headache-free period in February and March. In April, she developed severe headaches that occurred almost every day until June. She then had another period of relief until August, and so on.

The patient has no other past medical history and no allergies.

Upon examination, there are no remarkable findings.

What is the best prophylactic treatment for this patient’s headaches?

MRCP2-3445

A 32-year-old woman is brought to the Emergency Department after being found wandering aimlessly on the street. She has a history of drug abuse and has been living in a shelter. The shelter staff report that she has been coughing and losing weight for several months. On admission, she is disoriented and lethargic. Further tests reveal the following results:

Cerebral spinal fluid (CSF) cells Lymphocytic picture with 800 cells/cm per mm cubed < 5/mm3
CSF glucose 2.0 mmol/l 2.5–3.9 mmol/l
CSF protein 2.0 g/l < 0.45 g/l
Blood glucose 6.0 mmol/l 3.5–5.5 mmol/l
CT scan Obstructive hydrocephalus

What is the most likely diagnosis for this patient?

MRCP2-3446

A 28-year-old female patient comes to you with a sudden onset of vertigo and slurred speech that has been going on for 2 days. She has no medical history and does not smoke. During the examination, you observe partial ptosis and miosis on the left side. Her left arm’s finger-nose coordination is impaired, and she has decreased sensation to your cold tuning fork on her left face, right arm, and right leg. What is the probable diagnosis?

MRCP2-3438

A 78-year-old male presents to the clinic with a 9-month history of progressive confusion, unsteadiness on his feet, and new urinary incontinence. He has a minimal past medical history and takes ramipril for hypertension. On examination, he has a wide-based and ataxic gait, and his abbreviated mental test score is 3/10. The mini-mental state examination scores 16/30. A CT head shows no acute haemorrhages or infarcts, and an MRI reveals large ventricles with periventricular white matter changes. Lumbar puncture shows acellular cerebrospinal fluid with no organism growth, and the opening pressure is 16 cm H20. A CSF infusion test is arranged, which demonstrates raised CSF outflow resistance. What is the most appropriate treatment for this patient?

MRCP2-3439

A 78-year-old presents to the hospital with muscle cramps, fevers, and passing dark urine. The patient has a history of Parkinson’s disease and takes Sinemet 125 five times a day. Due to unforeseen circumstances, the patient’s daughter has been unable to pick up his medication for the past 5 days, resulting in the patient not taking his PD meds for 3 days. The patient’s blood pressure is fluctuating between 77/52 mmHg to 150/88mm Hg. Upon examination, the patient has a temperature of 39.2 degrees, quiet but present heart sounds, and unremarkable chest auscultation. The patient has rigid muscles in all four limbs, no obvious superficial evidence of head injury, and new confusion with an abbreviated mental test score of 0/10. The patient is started on intravenous fluids, intravenous broad-spectrum antibiotics, catheterized, and a nasogastric tube is inserted to administer his regular medications. What is the underlying diagnosis?

MRCP2-3440

A 28 year-old woman presents to the neurology clinic with complaints of headache and visual disturbance. She recently moved to the United States from Ghana. Her symptoms started about a month ago, shortly after giving birth to her first child. She experiences a dull frontal headache that is most severe in the mornings and when coughing or straining, as well as brief episodes of vision darkening. She was previously diagnosed with idiopathic intracranial hypertension by a doctor in Ghana and is currently taking acetazolamide 250mg twice daily as her only medication.

During the examination, her visual fields are significantly constricted, and the right blind spot is enlarged. Bilateral papilloedema is worse on the right, as seen on fundoscopy. The rest of the neurological examination is unremarkable. Her BMI is 18 kg/m². A plain computed tomography of the brain shows no abnormalities.

As she is leaving the clinic, she mentions that she has been experiencing pins and needles in her hands and feet.

What is the most appropriate course of action?

MRCP2-3441

A 49-year-old man presents to the emergency department after experiencing a 3-minute tonic-clonic seizure. He has no history of epilepsy and has never had a seizure before. He has been complaining of intermittent headaches and fevers for the past 10 days. The patient’s medical history includes hypertension, which is managed with amlodipine, ramipril, and indapamide once daily.

Upon examination, the patient is drowsy with a GCS of 13 (E3V4M6). His chest and heart sounds are normal, and his abdomen is soft and non-tender. The patient’s temperature is recorded as 38.1ºC.

A contrast-enhanced MRI scan is performed, as shown below:

Based on the likely diagnosis, what is the most probable causative pathogen?