An 80-year-old woman is brought to the Emergency department after being involved in a car accident 3 hours ago. She is currently maintaining her own airway with a respiratory rate of 18 breaths per minute and her SpO2 on air is 97%. Her heart rate is 85 beats per minute and her blood pressure is 140/70 mmHg. Upon examination, she has a visible bruise over the right temporal region and a Glasgow coma score (GCS) of 14. There are no other apparent injuries.
The patient has a medical history of hypertension and atrial fibrillation and is currently taking atenolol and warfarin. She does not remember the accident. While there is a radiology service available on site, the nearest neurosurgical unit is 40 miles away. What would be the most appropriate course of action for management?
MRCP2-3387
A 70-year-old patient was admitted to the hospital after experiencing VF arrest. The ambulance crew reported that CPR was initiated 3 minutes after an out-of-hospital downtime. In the resuscitation room, CPR was successful, and the patient was intubated after the return of spontaneous circulation. Three days later, upon extubation, the ITU consultant observed confusion and bilateral upper limb weakness, which was confirmed to be new with a collateral history. A CT head was performed, followed by an MRI head, which revealed small areas of ischaemic change in bilateral posterior parietal lobes, between middle and posterior cerebral artery territories. CT angiography showed 45% RICA stenosis and 60% L ICA stenosis. The cardiac monitor showed atrial fibrillation, and the echocardiogram revealed septal akinesia, consistent with a recent MI. What is the probable cause of this patient’s stroke?
MRCP2-3388
A 77-year-old man is admitted after being found on the floor at home with no recollection of how he got there or how long he had been there. He complains of feeling generally unwell and having a cough for several days. He has no significant medical history and takes no regular medications. He lives alone and appears disheveled. During examination, bronchial breathing is heard throughout his left mid zone, and he exhibits new onset weakness in left-sided shoulder abduction and adduction, as well as mild weakness in left elbow flexion. Additionally, reduced sensation in the lateral aspect of his upper arm is noted. A CT head is performed.
CT head report shows age-related involutional change with no evidence of intracranial hemorrhage or recent ischemic event.
What is the most likely diagnosis?
MRCP2-3390
A 75-year-old male presents with a two-year history of progressive unsteadiness on walking. He had previously been very active, walking around 3 miles every day and only retired as a teacher 4 years ago. He underwent chemotherapy for localised squamous cell carcinoma of his tongue 20 months ago but otherwise had no other past medical history. He admits to having drunk ‘more than he should have’ while in college but says he has since cut down to moderate levels. He stopped smoking 6 years ago, with a 35 pack year history. Over the past 4 months, he has become incontinent of urine and has to rely on pads, which he is greatly embarrassed by.
On examination, he has a shuffling gait in his lower limbs with good arm swing. He is markedly slowed and takes 130 seconds to walk 25 metres. He turns around 180 degrees in 7 steps with no resting tremor, rigidity or bradykinesia. Examination of his tone, power, sensation, coordination and reflexes are all unremarkable. His voice is quiet and whispering. His cranial nerves are normal with a full range of eye movements. An abbreviated mental test scores 8/10, a Montreal cognitive assessment (MOCA) scored 28/30. His initial blood tests are as follows:
An MRI head is performed, demonstrating diffuse mild microangiopathic changes with prominently dilated lateral and third ventricles. No intracranial masses are noted. You perform a lumbar puncture, with the patient lying in the left lateral position using a 22G spinal needle and obtain cerebrospinal fluid with the first pass. His opening pressure is 17.2 cmH2O. What is the most appropriate course of action?
MRCP2-3391
A 38-year-old male presents to your outpatient clinic with a progressive history over the past 5 years of increasing, progressive ‘clumsiness’. His work colleagues had a long running joke with him that he is poorly coordinated for about the past five years but in recent weeks, he has noticed that he is unable to write legibly or even hold a key still using either hand to open a door. He denies any recent weight loss of night sweats, is otherwise healthy with no other past medical history. He is a lifelong non-smoker with a minimal alcohol history and lives with his wife and 2 children.
On examination, his cranial nerves were unremarkable except for mild multidirectional nystagmus at primary gaze. Fundoscopy was normal. Limb examination revealed a significant impairment of finger-nose and heel-shin testing. His gait, tone, power, sensation and reflexes were normal with downgoing plantars. A brief mini-mental state examination scored 30/30. An MRI head is awaited. His blood tests are as below:
Which investigation is most likely to yield the diagnosis?
MRCP2-3392
A 55-year-old Caucasian female from Australia is seen at the walk-in urgent care centre with a persistent left-sided temporal headache and double vision that has been gradually developing over the past four days. Although she has a history of migraines, they are usually well-controlled. She is independent and has no significant family history, and she only takes the oral contraceptive pill. During the examination, you observe a loss of the afferent pupillary reflex on the left side, as well as a loss of vertical gaze and an inability to adduct her left eye. Additionally, she has reduced sensation to light touch on the left forehead and cheek, but it does not cross the midline. What is the most probable diagnosis?
MRCP2-3393
A 45-year-old female presents with a second episode of loss of sensation in her left anterior thigh and right foot. This is her second episode within the past six months. She had recently reported an episode of left anterior shin numbness 2 years ago when an MRI with gadolinium demonstrated ‘spots in her spinal cord’ and she was diagnosed with transverse myelitis. Her past medical history also includes ulcerative colitis, diagnosed aged 28 years old and primary sclerosing cholangitis. Her serum tests are as follows:
What would be the most appropriate next step in management after commencing five days of high dose oral methylprednisolone?
MRCP2-3394
A 55-year-old male is brought to the emergency department by his worried wife after falling down a flight of 12 stairs at home and hitting his head. Despite his wife’s concerns, the patient does not seem worried and thinks he could have stayed at home. He denies experiencing a headache, nausea, vomiting, seizures, or loss of consciousness between the fall and examination. He is not taking any regular medications, including anticoagulants, and remembers everything except for about 20 seconds after landing at the bottom of the stairs. During the examination, there is no limb weakness or loss of sensation, and his pupils are equal and reactive bilaterally. What is the most appropriate course of action?
MRCP2-3395
A 29-year-old gentleman student from Germany presents to you with right foot drop ongoing for two weeks with some numbness and tingling of the foot. These symptoms developed after he knelt down to pick something up from the floor. Three years ago he woke up from sleep with clawing of his fourth and fifth digit after having been asleep in a prone position and this lasted a week. Eight years ago he also had a left wrist and finger drop lasting three weeks after he sat on the couch with his left arm draped over the back of the couch for ten minutes. He denies falling asleep or remaining on the couch for a prolonged period. He has no other past medical history of note and has never sought medical advice for his problems.
On examination, there is right foot drop (2/5 power) and similar weakness of dorsiflexion and eversion of the right foot. There is also sensory loss over the lower lateral part of the right leg and dorsum of the right foot in all modalities. Reflexes are intact. Neurological examination and general examination are otherwise unremarkable. Which of the following tests would confirm the suspected diagnosis?
MRCP2-3398
A 65-year-old man presented to his GP with a six-month history of hoarse voice and choking episodes. In the last few weeks, he had also experienced pulsatile ringing in his left ear with some associated hearing loss. He denied any headache, weight loss, or vomiting and had not noticed any problems with his arms or legs.
The patient had a past medical history of renal stones and hypertension and took allopurinol. He was a smoker of 25 cigarettes per day and did not drink alcohol.
During the examination, the patient had a husky voice with a nasal quality to his speech. There was a left Horner’s syndrome, but pupils were reactive to light and ocular movements were full. Facial movements were normal, and there was no obvious reduction in hearing. On examining the throat, there was sluggish movement of the palate on the left and evidence of left-sided tongue wasting. There also appeared to be some difficulty in shrugging the left shoulder with weakness of chin movement to the right. The remainder of the neurological examination was normal.
Based on the patient’s history and clinical findings, what is the most likely diagnosis?