Archives: MRCP Part 2

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?

MRCP2-3444

A 65-year-old man returns to neurology clinic for review with his wife. He was diagnosed with Parkinson’s disease three years ago and was started on ropinirole nine months ago as his symptoms were becoming difficult to manage. He was mainly concerned with the rigidity of his movements. Since then he has improved remarkably, and his movements are much better, with reduced rigidity on examination. His mood has also been improving with the relief from his symptoms.

However, his wife has become concerned that he has been increasingly spending large amounts on shopping, something which he has not done before and that she feels is out of character. What is the most likely explanation?

MRCP2-3420

A 25-year-old woman with a history of epilepsy presents to the Emergency department with worsening generalised headache, vomiting, unsteadiness, and blurred vision over the past three days. She has also experienced slurred speech and a one stone weight loss in the past month. On examination, she has dysarthria, bilateral papilloedema, reduced visual acuity, and a broad-based ataxic gait. Investigations reveal bilateral cerebellar haemangiomas. What is the probable diagnosis for this patient?

MRCP2-3421

A 43-year-old woman presents to neurology clinic for evaluation of her treatment plan for multiple sclerosis. She was diagnosed with multiple sclerosis five years ago after experiencing sensory loss and motor weakness in her left leg. Despite having multiple lesions on MRI suggestive of multiple sclerosis, she initially declined disease modifying therapy. However, one year later, she developed optic neuritis and had progression of her radiographic lesions on repeat MRI. She was then started on interferon beta for two years but discontinued due to intolerable side effects. A trial of glatiramer acetate was also unsuccessful due to severe flushing. Since stopping disease-modifying therapy, she has had multiple relapses, including one requiring hospitalization. She meets criteria for aggressive or highly active multiple sclerosis and is interested in later line therapies. She is a science teacher who has been unable to work for the past year due to her relapses.

At this point, the recommended later line therapy is natalizumab. What is the crucial investigation that must be completed before starting treatment with natalizumab?

MRCP2-3422

An 80-year-old man presents with gradually worsening dyspnoea, without any accompanying cough or chest pain. He has a medical history of Parkinson’s disease, rheumatoid arthritis, type 2 diabetes mellitus, and atrial fibrillation. Peak flow tests reveal a decreased Forced Vital Capacity (FVC), an FEV1:FVC ratio of 90%, and a reduced transfer factor for carbon monoxide (TLCO). A high-resolution CT scan confirms the presence of ground-glass changes. Which medication among his current prescriptions is the most likely cause of his lung changes?

MRCP2-3423

A 28-year-old male presents with sudden left-sided weakness, expressive dysphasia, and dress apraxia. He has a history of progressive cognitive impairment and seizures for the past six years. He lives in a sheltered accommodation and was brought in by his relatives who noticed a change from his baseline. The patient has difficulty recalling the duration of his symptoms. He reports a recent burning sensation while urinating, increased frequency, and reduced oral intake for the past five days. An MRI of the head shows multiple areas of ischemia in the left and right cortex, inconsistent with a single vascular territory. A urine dip test is positive for leukocytes and nitrites but negative for ketones. A venous blood gas test reveals:

pH 7.15
PaCO2 2.4 kPa
Bicarbonate 6 mmol/l
Lactate 18 mmol/l
Anion gap 16 mmol/l

What is the underlying diagnosis that explains all of these symptoms?

MRCP2-3424

A 50-year-old Bangladeshi male presents with a 6-month history of bilateral reduced sensation on the tips of both his feet, which has gradually progressed on both legs to his low shins. His past medical history includes type 2 diabetes, diagnosed 10 years ago and reports good medication compliance with metformin 500mg BD alone, with a HbA1c of 48 mmol/mol (6.5%) two weeks ago. He is also currently in his ninth month of anti-tuberculosis treatment, having initially presented with a chronic cough, night sweats and weight loss. An induced sputum subsequently cultured positive for acid-fast bacilli. He did not bring in his medications but remembers being told they are ‘the standard four then two drugs’. He takes no other medications and has no known drug allergies. On examination, tone, power and gait of his lower limbs are unremarkable. He demonstrates reduced sensation to light touch to his left lower shin and right mid-shin. Ankle jerks are absent bilaterally, plantars are downgoing bilaterally. What is the most likely diagnosis?

MRCP2-3425

A 70-year-old male has been diagnosed with dementia after experiencing a gradual decline in cognitive function over the course of a year. Specifically, he has shown deficits in planning, attention, cognitive flexibility, visual memory, and visuospatial manipulation on detailed neuropsychological assessments. His mini-mental state examination score is 15 out of 30. The patient has a history of Parkinson’s disease and has been taking Madopar for the past 6 years. During a clinic visit, the patient’s son expresses a strong desire to start treatment. What is the most readily available treatment option?

MRCP2-3426

A 79-year-old male visits a Parkinson’s disease clinic complaining of frequent episodes of complete immobility lasting up to 20 minutes, occurring up to four times daily. He has been diagnosed with Parkinson’s disease for the past six years and is currently taking Sinemet 125 as his only medication. What is the most suitable treatment to alleviate his motor fluctuations?