Archives: MRCP Part 2

MRCP2-3367

A 55-year-old accountant presents with a constant headache for the past two weeks and has had two seizures in the last 24 hours. His family reports a change in his character, increased aggression, weakness, decreased appetite, and a weight loss of 2 lbs over the past week.

The patient has a history of HIV and underwent an anterior resection for rectal carcinoma three years ago. A recent endoscopy revealed gastric polyps. He is currently taking oral antibiotics for sinusitis.

On examination, the patient has reduced power in the left upper limb and reflexes are reduced on the left side. Power is mildly reduced in the left lower limb with an upgoing plantar and normal sensation. The patient has a Glasgow Coma Score of 13 and is drowsy. Pupils are equal and reactive, but there is papilloedema. His observations show a heart rate of 96 beats per minute, blood pressure of 110/98 mmHg, temperature of 38.0’C, and respiratory rate of 18 per minute with saturations of 98%.

Lab results show a normal electrolyte balance and creatinine levels, but the patient has a low hemoglobin count and elevated white blood cell count. Blood cultures are pending, and a CT head has been requested.

What is the likely diagnosis?

MRCP2-3368

A 22-year-old male presents with a sudden and severe headache accompanied by disorientation, drowsiness, and neck stiffness. Upon investigation, a subarachnoid haemorrhage is suspected. What is the patient’s grade of illness according to the Hunt and Hess scale?

MRCP2-3371

A 25-year-old woman presents with a referral to neurology due to progressive weakness in her lower limbs over the past 5 weeks, resulting in difficulty walking. She also reports experiencing bilateral tinnitus for the past 4 months, accompanied by episodes of vertigo. On examination, both lower limbs exhibit reduced power (3/5), increased tone, and hyperreflexia. A single 1 cm tan lesion is observed on her torso, but no other skin lesions are detected. An MRI of her spine is ordered. What is the most probable diagnosis?

MRCP2-3372

A 60-year-old man presents to the neurology outpatient clinic with a six-month history of double vision. He first noticed this when reading before going to bed, but it has been occurring earlier in the day whenever he concentrates on an activity. His wife reports struggling to hear him when he speaks and that his eyelids have drooped late in the day. The patient denies experiencing any weakness in his arms or legs but has limited mobility due to osteoarthritis of both knees. He has a past medical history of hypercholesterolemia, hypertension, and diverticular disease. What is the most sensitive investigation for the likely diagnosis?

MRCP2-3373

A 45-year-old right-handed male accountant has come to your general medical clinic in a state of distress. He has been experiencing difficulty writing for the past 2 weeks. He explains that he wants to write, but his hand stops as soon as he picks up the pen. He has no medical history, lives with his wife, and does not smoke or drink alcohol. During the neurological examination, there were no notable findings. However, when asked to write, his hand and fingers suddenly flex, resulting in illegible handwriting. What is the most probable diagnosis?

MRCP2-3374

A 65-year-old woman presents with constant thoracic back pain that is severely impacting her ability to care for her grandchildren. She has a medical history of breast cancer, which was treated with a mastectomy, reconstruction, radiotherapy, and endocrine therapy. Due to being BRCA1 positive, she also had a hysterectomy with bilateral oophorectomy. On examination, she experiences tenderness over the T4 spine, but there are no neurological abnormalities. What imaging investigation is best suited for her back pain?

MRCP2-3378

A 60-year-old woman presented to the neurology clinic with a complaint of progressive weakness over the past 3 months. She initially noticed difficulty opening jars, but over the past month, she also experienced difficulty walking up stairs. She denied any pain or changes in sensation. Her medical history included osteoporosis, type 2 diabetes mellitus, and hypertension.

During the neurological examination, there were no fasciculations, and the sensation was intact. However, power was reduced in finger flexion (3/5), wrist flexion (4/5), knee extension (3/5), and hip flexion (4/5) bilaterally. Upper limb reflexes were present but diminished, and the knee jerk was absent. The plantar response was flexor bilaterally. There was no tenderness over any muscle groups. Cranial nerve examination was unremarkable.

The following blood results were obtained:

– Haemoglobin: 122 g/l
– White cell count: 8.2 x 10^9/l
– Platelets: 376 x 10^9/l
– C reactive protein: 7 mg/l
– Erythrocyte sedimentation rate: 39 mm/hr
– Creatine kinase: 272 (24-170 U/l)

What is the most likely diagnosis?

MRCP2-3379

A 35-year-old female presents to the neurology outpatient department with complaints of severe right-sided throbbing headaches localized to the temporal region. The headaches occur abruptly and last for about 15 minutes, happening 9-12 times a day. She also experiences nasal congestion and rhinorrhoea. She has a family history of migraine and smokes ten cigarettes per day. She does not drink alcohol and has no significant past medical history. On examination, there are no neurological abnormalities. Laboratory investigations and MRI brain are normal. Which medication is the most appropriate treatment for her symptoms?

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?