Archives: MRCP Part 2

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:

Hb 125 g/l
Platelets 274 * 109/l
WBC 7.5 * 109/l

Na+ 139 mmol/l
K+ 4.4 mmol/l
Urea 4.7 mmol/l
Creatinine 78 µmol/l
Bilirubin 49 µmol/l
ALP 305 u/l
ALT 180 u/l

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?

MRCP2-3396

A 72-year-old right-handed male presents with sudden onset flaccid left upper and lower paralysis with complete dysphasia. His son reports him to have been well two hours ago.

On examination, the patient scores 0/5 on his left upper and lower limb, at least 4/5 on both right limbs (examination was difficult due to his dysphasia), with a loud carotid bruit. He is also now in atrial fibrillation, a new diagnosis for him. He is well known to the stroke team: 8 weeks ago, he was admitted with a left middle cerebral artery ischaemic stroke, leaving him with minimal residual weakness on his discharge.

During his admission, he was found to have 80% carotid stenosis in his left internal carotid artery and 70% in his right internal carotid artery, for which he declined surgery. His other past medical history includes hypertension, type 2 diabetes mellitus and dyslipidaemia. He does not take any anticoagulants. A CT head demonstrates a hypodensity in the right middle cerebral artery area distribution, consistent with an acute ischaemic stroke with no areas of haemorrhagic transformation.

What is the most appropriate next course of action?

MRCP2-3397

A 48-year-old woman presents to her GP with complaints of fatigue and weakness. She reports feeling completely drained by the end of the day and has difficulty with simple tasks such as combing her hair and walking down stairs. She has also noticed excessive drooping of her eyes and occasional double vision. The patient is a smoker, has rheumatoid arthritis, and recently started taking propranolol for tension headaches. On examination, she exhibits bilateral ptosis, oculoparesis on right lateral gaze, and weakness of neck extension. Blood tests reveal positive muscle-specific kinase antibodies and negative anti-acetylcholine receptor antibodies. A CT scan shows thymic atrophy with no other masses. How would you initially manage this patient?

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?

MRCP2-3399

A 48-year-old man presented to the neurology clinic with complaints of double vision and flu-like symptoms for the past five days. He reported difficulty closing his right eye fully and noticed a similar problem with his left eye. The patient had recently been diagnosed with type 2 diabetes mellitus and was following a diabetic diet. He had no significant medical history and did not take any regular medication. On examination, the patient had oculoparesis affecting the right lateral rectus and right superior oblique muscle, bilateral facial weakness, and bilateral Bell’s phenomena. He also had arthralgia in his hands and knees. Lumbar puncture revealed elevated CSF protein and white cell count with the presence of oligoclonal bands. MRI brain scan showed punctate periventricular white matter lesions. What is the likely diagnosis?

MRCP2-3400

A 25-year-old woman presents to the Neurology Clinic with a 6-month history of diffuse headaches. Initially, the pain occurred only at certain times during the week, but it has now become continuous. She reports that the pain is worse in the morning and she has experienced mild nausea. Her medical history includes depression and acne vulgaris, and she is currently taking fluoxetine, the oral contraceptive pill, and tetracycline.

During the examination, Frisen stage 1 papilloedema affecting both eyes is observed, along with an enlargement of the blind spot and some diplopia on the left lateral gaze. Her body mass index is 32 kg/m2, and there are no other neurological signs.

A magnetic resonance brain scan is performed, which shows no space-occupying lesion. Cerebrospinal fluid (CSF) analysis demonstrates an opening pressure of 33 cmH2O.

What is the next best step in management, given the likely diagnosis?

MRCP2-3380

A 20-year-old male patient visits the clinic with a complaint of motor and verbal tics that are causing him embarrassment. He was diagnosed with Tourette syndrome at the age of 16 and had undergone habit reversal therapy (HRT) which provided partial relief. However, his symptoms have worsened now. He has no significant medical history and is not on any regular medication.

What medication would you prescribe to block the effects of dopamine in the basal ganglia for this patient?

MRCP2-3381

A 65-year-old retired teacher was admitted to a Neurology Ward 3 weeks ago following a series of seizures. Her family report that she was last completely well 6 months ago.
At that time, a change in her behavior was noted with frequent forgetfulness, confusion, and difficulty with simple tasks. Over the next few weeks, she was reported to be increasingly irritable and agitated. In the following weeks, her family have noticed that she has been increasingly unsteady on her feet, often stumbling and having difficulty with balance. The neurology team are concerned about continued cognitive deterioration, despite treatment for a recent suspected infection, and have referred her for medical advice. Over the last week, jerking movements have also been noted in her arms.
On examination she is confused, bed-bound and catheterised with spontaneous and stimulus-sensitive myoclonus. Mini-Mental State Examination reveals a score of 10 out of 30, with global deficits. A bilateral grasp reflex together with pout and snout reflexes are present. Tone is increased in all of the limbs, with symmetrically brisk reflexes and bilateral extensor plantars. Although she has difficulty following commands, there is demonstrable ataxia and apraxia of the upper limbs.
Which one of the following investigations is most specific in securing the diagnosis in this case?