Archives: MRCP Part 2

MRCP2-3377

A 28-year-old man presents to the hospital after feeling unwell at a gathering. Upon arrival, he is found to be lethargic and only responsive to verbal cues. His airway is open, and his lungs are clear. His pupils are reactive to light and measure 4mm. His vital signs are as follows:

– Respiratory rate: 12 breaths per minute
– Oxygen saturation: 95% on room air
– Heart rate: 84 beats per minute
– Blood pressure: 117/65 mmHg
– Temperature: 36.7ºC

Due to his altered mental status, a CT scan of his head is ordered. During the scan, a friend calls the hospital and reports that the patient had taken some pills at the party about 90 minutes ago. Empty packets of diazepam were found at the scene.

After the CT scan, the patient returns to the ward, but his level of consciousness deteriorates, and he begins to make snoring sounds. These sounds improve with a jaw thrust but return when the maneuver is stopped. The rest of the physical examination is unchanged.

What is the most appropriate course of action?

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?

MRCP2-3382

A 35-year-old woman presents with a complaint of reduced sensation. She reports that over the course of six months, she has not been able to feel when hot water splashes on her hands, despite developing blisters afterwards. Her husband has urged her to seek medical attention. She denies any other issues, including weakness, weight loss, or difficulty with daily activities. She has a history of asthma but only uses her salbutamol inhaler infrequently. She has no known allergies or other medications. Upon examination, she exhibits sensory loss in the dermatomes C4 to C6, with a symmetrical distribution affecting her hands and arms when tested for temperature and pain. There is no tenderness upon spinal examination, and her cranial nerve and lower limb examinations are normal. What is the most likely diagnosis?

MRCP2-3352

A 65-year-old man presents with a six-week history of lower back pain that worsens with coughing. He has noticed an increase in his painkiller intake, especially at night, and experiences more pain when straining to pass stool. He has also lost three kg over the last five months. His medical history includes COPD, hypertension, type two diabetes mellitus, and hypercholesterolemia. He has been hospitalized three times in the past year for COPD exacerbations requiring oral prednisolone. He takes Symbicort, tiotropium, atorvastatin, metformin, paracetamol, codeine, and Movicol. He is an ex-smoker with a 50 pack-year history and recently retired early from his job as an accountant due to fatigue. On examination, he appears fatigued and his clothes are loose fitting. There is a 1 cm swelling above his left clavicle, but his chest examination is unremarkable. His abdomen is soft, there is no tenderness over his spine, and a neurological examination is normal.

Observations:
Saturations 95%
Respiratory rate 15/min
Blood pressure 148/87 mmHg
Heart rate 74/min
Temperature 37.4°C

Blood tests:
Hb 128 g/l
MCV 72 fl
Platelets 327 * 109/l
WBC 12.4 * 109/l
Na+ 136 mmol/l
K+ 4.2 mmol/l
Urea 4.1 mmol/l
Creatinine 77 µmol/l

What is the most likely diagnosis to explain his symptoms?

MRCP2-3353

A 67-year-old male presents to the emergency department via ambulance with a sudden onset of bilateral weakness that has been progressing for the past 5 hours. The patient has a medical history of hypertension and hypercholesterolemia and is currently taking amlodipine, ramipril, and atorvastatin. He is a non-smoker.

Upon examination, the patient displays bilateral flaccid weakness in the lower limbs with a power of 0/5 in all muscle groups. The patient is also areflexic and has lost pain and temperature sensation from the level of the umbilicus to the feet. However, proprioception and vibration sense remain intact.

Over the next few weeks, the patient’s weakness becomes spastic in nature, with the lower limbs developing hyperreflexia and upgoing plantar reflexes.

What is the most likely diagnosis?

MRCP2-3356

A 58-year-old woman presents to the acute medical unit with a frontal headache that has been worsening, along with nausea and pins and needles in her distal right upper limb. She was born in India and moved to the United Kingdom three years ago. Her medical history includes tuberculosis that was treated 10 years ago and rheumatoid arthritis, for which she has recently started taking methotrexate, sulfasalazine, and a short course of oral prednisolone. Her chest X-ray was normal, and the quantiFERON test was negative when she entered the UK.

Upon examination, the patient appears well and is alert and oriented. Her vital signs are within normal limits, and there is symmetrical swelling in the small joints of both hands. Neurological examination reveals 4/5 MRC grade of power in the distal right upper limb. Examination of the cardiovascular, respiratory, and abdominal systems reveals no additional abnormalities.

The patient’s investigation results are as follows:

– Hb 124 g/L
– Platelets 398* 109/L (150 – 400)
– WBC 12 * 109/L (4.0 – 11.0)
– Na 135 mmol/L (135 – 145)
– K 3.6 mmol/L (3.5 – 5.0)
– Urea 5 mmol/L (2.0 – 7.0)
– Creatinine 63 µmol/L (55 – 120)
– CRP 24 (< 5) A contrast CT head is arranged, which shows a 3-4 cm diameter homogeneous contrast-enhancing round lesion adjacent to the meningeal membrane situated in the left frontal lobe with evidence of surrounding edema and mass effect. No additional lesions are noted, and there is no evidence of acute ischemia, hemorrhage, or collection. What is the most likely diagnosis?

MRCP2-3357

A 24-year-old man is brought to the ITU after being medically transferred from India. He had been travelling in India for approximately four weeks before experiencing symptoms of illness. According to his girlfriend, he was behaving unusually and had several seizures before being admitted to a hospital in Patna, eastern India. The patient underwent a scan and a surgical procedure in India, which was ultimately abandoned.

A CT scan of the head with contrast is conducted:

What is the probable diagnosis?