Archives: MRCP Part 2

MRCP2-3433

A 35-year-old female presents to the neurology clinic with a 6-month history of headaches. She reports experiencing throbbing headaches most days upon waking up, which improve after mobilization but worse with coughing. She has had a few instances of blurred vision upon waking up, but no nausea or vomiting. Her BMI was previously 27 kg/m², but she has since lost weight and now has a BMI of 23 kg/m². She takes paracetamol and ibuprofen regularly for her headaches but is not on any other medications. On examination, there are no focal neurological deficits, and her visual acuity is normal. Mild papilloedema is noted on fundoscopy, and her blood pressure is 125/82 mmHg. Blood tests are unremarkable. What is the most appropriate next step in management?

MRCP2-3434

You are requested to assess a 31-year-old man who was brought to the hospital by ambulance following an assault. According to a witness, he lost consciousness and has since become increasingly drowsy. His current GCS score is 9/15 (E2 V3 M4), making neurological examination challenging. However, his pupils are symmetrical, and he has an extensor right plantar. The CT brain scan below shows a cross-section of his brain.

Based on the information provided, which aspect of the patient’s history is linked to a worse prognosis?

MRCP2-3435

A 55-year-old woman presented to her GP with a four month history of progressive distal sensory loss and weakness of both legs and arms. The weakness and numbness had extended to the elbows and knees.

On examination, cranial nerves and fundoscopy were normal. Examination of the upper limb revealed bilaterally reduced tone and 3/5 power.

Lower limb examination revealed some mild weakness of hip flexion and extension with marked weakness of dorsiflexion and plantarflexion. Both knee and ankle jerks were absent and both plantar responses were mute. There was absent sensation to all modalities affecting both feet extending to the knees.

A lumbar puncture was performed and yielded the following data:

Opening pressure 14 cm H2O (5-18)

CSF protein 0.75 g/L (0.15-0.45)

CSF white cell count 10 cells per ml (<5 cells) CSF white cell differential 90% lymphocytes – CSF red cell count 2 cells per ml (<5 cells) Nerve conduction studies showed multifocal motor and sensory conduction block with prolonged distal latencies. What is the likely diagnosis in this patient?

MRCP2-3436

A 65-year-old woman visits her GP complaining of progressive numbness and difficulty walking. Her daughter, who accompanies her, reports that she has been exhibiting strange behavior for the past few months. The patient has a history of ileal resection for Crohn’s disease that was resistant to treatment, nine years ago.

Upon laboratory testing, the patient’s haematocrit and mean corpuscular volume were found to be low. Additionally, macrocytic red blood cells with hypersegmented neutrophils were observed in the blood smear analysis.

What is the most probable cause of the patient’s symptoms?

MRCP2-3437

A 65-year-old woman presents to neurology clinic following a referral from her GP due to intermittent facial pain. The patient first noticed symptoms approximately 9 months ago, with the initial attack occurring while attending a fireworks display with her grandchildren. The pain is described as a severe sewing sensation affecting the right side of her face, lasting for 1-2 minutes before resolving completely. Since the onset, the patient reports experiencing at least one attack on most days, with the frequency seeming to increase over time. Although the patient has experienced a blocked nose and sweating during some episodes, these symptoms are not as concerning as the severe pain. The patient denies any other symptoms and is otherwise in good health, with no recent history of weight loss. There is no family history of neurological disease.

During the consultation, the patient experiences a new episode of pain, allowing for further examination. Conjunctival injection and slight eyelid edema of the right eye are noted, along with profuse sweating on the right side of the face. The patient confirms the onset of a blocked nose sensation at the start of the pain.

What is the most likely diagnosis responsible for the patient’s symptoms?

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?

MRCP2-3440

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?

MRCP2-3442

A 36-year-old female presents to the Emergency Department with a three-day history of increasing weakness in the left arm and reduced visual acuity in the left eye. She was diagnosed with relapsing-remitting multiple sclerosis three years ago and is compliant with her fingolimod maintenance therapy.

Upon examination, she exhibits weakness in wrist extension and finger abduction in the left hand, and her left eye’s visual acuity is measured at 6/24 with a corresponding reduction in colour saturation. Her blood tests are unremarkable, and her white cell count is normal. However, her MRI scan reveals two new enhancing lesions in the right pericallosal region.

What is the appropriate acute management for this patient?

MRCP2-3443

A 58-year-old man presents to the emergency department after collapsing 2 hours ago. His partner witnessed the fall and reported that he has not been able to move his right arm and leg since. The patient had no prior medical issues. Upon examination, he is drowsy with a Glasgow coma score of 10 out of 15 and a blood pressure of 165/92 mmHg. He has a right-sided facial droop and no movement in his right arm or leg. He is a smoker and takes amlodipine for hypertension. An urgent CT head scan reveals loss of differentiation between the grey and white matter in the left frontal and parietal lobes, but no acute haemorrhage. What is the most appropriate initial management?