Archives: MRCP Part 2

MRCP2-3336

A 65-year-old man was brought to the Emergency department after a fall in his bathroom.

Seen immediately by his family, he was already picking himself up from the floor and said he was not injured. His wife felt that he was transiently dazed.

On examination, he was alert, and no abnormalities were noted. His medical history included a history of hypertension for which he was taking bendroflumethiazide 2.5 mg daily. He was discharged without any further intervention.

Two weeks later his wife brings the patient to see you because the dazed state has returned. Examination reveals a temperature of 36.7°C, a pulse rate of 84 bpm regular, a blood pressure of 152/94 mm Hg.

On questioning he is slightly slowed, being disoriented to time with some deficit in recent memory. The patient moves slowly, but power is normal. Neurologic examination shows slight hyperactivity of the tendon reflexes on the right with unclear plantar responses because of bilateral withdrawal.

What tests or evaluations would you request?

MRCP2-3337

A 24-year-old university student presented with a year long history of occipital headache. This was worse on coughing, sneezing and straining and partially relieved by lying flat. On one occasion the headache had been associated with vomiting. She had previously consulted her family doctor who was treating her for migraine. Over the past two months she had noticed pain in her both arms and felt unsteady on her feet.

On examination touching her arms caused pain and there was reduced appreciation of pinprick and temperature sensation throughout both arms. Tone, power and reflexes in the upper limbs were normal. On testing upper limb co-ordination there was some past-pointing and a very mild intention tremor. On inspection of the feet there was pes cavus and Romberg’s test was positive. Again tone, power and reflexes were normal in the lower limbs and plantars were downgoing. Proprioception was impaired with absent joint position sense until the level of the knee. Vibration sensation was impaired in both feet.

Based on the clinical findings described above, what is the most likely diagnosis for this 24-year-old university student?

MRCP2-3338

A 36 year old construction worker presents to the emergency department after sustaining a severe cut to his upper arm while on the job. During the suturing process, the physician notices multiple burns and cuts on both of his arms.

Upon examination, the patient displays significant atrophy of the brachioradialis and small muscles in both hands, along with mild hyporeflexia of the biceps and brachioradialis tendons. He experiences weakness in both arms, particularly distally. However, his lower limb and cranial nerve assessments are unremarkable. Upper limb sensation, vibration, and proprioception are intact, but there appears to be reduced pain and temperature sensation over the C3/C4/C5 dermatomes. What diagnostic test would be most beneficial in this case?

MRCP2-3339

A 42-year-old chef presents to a neurologist with progressive wasting and weakness of the right hand. He has been experiencing reduced dexterity and clumsiness while at work for several months. Additionally, he has burnt his hands while cooking or smoking without realizing it, resulting in multiple sores over the fingertips of both hands. He has no known medical history but did sustain a whiplash injury in a recent minor car accident. On examination, there is evidence of right dorsal interossei, hypothenar eminence, adductor pollicis brevis, and forearm wasting. Power, handgrip, and wrist flexion/extension are asymmetrically weak (right>left). Sensation is reduced for pain and temperature affecting both arms and anterior/posterior chest wall. What is the likely diagnosis for this patient based on the history and examination findings?

MRCP2-3340

An 80-year-old resident of a nursing home presented to the neurology clinic with a history of Alzheimer’s disease. Her behavior had become increasingly challenging over the past four months, leading to the initiation of regular haloperidol. However, the nursing home staff reported that over the last four weeks, she had developed involuntary movements of her mouth, including frequent tongue protrusion and lip-smacking. Despite stopping the haloperidol two weeks ago, her symptoms had worsened. On examination, she displayed continuous involuntary lip-smacking, tongue protrusion, and frequent eye-blinking, but was otherwise well and alert. What is the most likely cause of her symptoms?

MRCP2-3341

A 72-year-old man presents to the Emergency Department after experiencing a sudden collapse. Prior to the collapse, he had been complaining of a severe headache at the back of his head. The patient has a medical history of hypertension, which is being managed with two oral medications.

Upon examination, the patient’s mean arterial pressure is 140 and his pulse is regular at 88 beats per minute. Bilateral papilloedema is observed, and the patient’s Glasgow Coma Scale score is reduced to 13. Despite confusion, the patient is able to move all four limbs. A CT scan of the head reveals evidence of a large subarachnoid haemorrhage.

What is the target for cerebral perfusion pressure in this patient?

MRCP2-3342

A 25-year-old woman presents with a fever and headache that started suddenly and has worsened over the past 24 hours. She is experiencing difficulty looking at lights and neck stiffness. Upon examination, she is febrile and photophobic, but has no focal neurological deficits or rash. A lumbar puncture is performed and the results show elevated lymphocytes and protein levels, as well as a positive viral PCR for Herpes simplex virus type 2. She is currently receiving IV ceftriaxone and dexamethasone for presumed bacterial meningitis. What is the most appropriate course of action?

MRCP2-3343

A 55-year-old Asian woman with a medical history of hypertension, ischemic heart disease, type 2 diabetes mellitus, and colon cancer resected two years ago, presents to the Emergency department with a one-week history of cough and shortness of breath. She has been experiencing chronic mild right ear ache with some discharge and mild right-sided headache, but no reported neck stiffness or photophobia. Occasionally, she has been choking when drinking and her voice has become hoarse.

During examination, the patient was afebrile and had normal vital signs. There were scarce crepitations on the right base of lung. Cranial nerve examination revealed deviation of uvula to the left and her left palatolingual fold was positioned higher than the right. On protrusion, the tip of the tongue was deviated to the right. Limb examination was normal with negative Babinski’s sign bilaterally.

Blood results showed normal levels of sodium, potassium, creatinine, urea, albumin, total bilirubin, alkaline phosphatase, and ALT. However, the patient had an elevated ESR and CRP. Her hemoglobin, WBC, and platelet counts were within normal ranges, but her neutrophil count was slightly elevated.

What is the most likely diagnosis for this patient?

MRCP2-3344

A 32-year-old woman presents to the General Neurology Clinic with a history of progressive gait deterioration over the past 14 years, requiring the use of a frame for assistance. She also reports a gradual decline in her hearing over the last 3 years. Upon further inquiry, it is discovered that her maternal grandmother had a history of seizures, her mother experienced hearing loss in her 50s, and her mother’s sister was diagnosed with multiple sclerosis. What is the most probable diagnosis in this case?

MRCP2-3345

A 20-year-old woman presents to her clinic appointment in distress. She has been experiencing severe headaches for the past year, causing her to drop out of her university studies. The headaches are debilitating and often prevent her from doing anything else. She experiences vomiting most days of the week when the pain is at its worst, and her vision feels blurry. Despite trying sumatriptan, NSAIDs, paracetamol, and relaxation techniques, her GP has been unable to provide much relief. She is currently taking sertraline for depression and does not smoke.

The patient’s headaches are a constant, severe frontal headache with radiation around the eyes. She can vomit at times, often before breakfast. She has rarely found relief from her symptoms, but notes that they are better in the evenings.

On examination, the patient has normal visual fields, equal limb strength, and normal tone. There is no sensory loss. Her fundi show no bleeds or exudate, but the disc is blurred. She has a raised body mass index of 26kg/m² and is afebrile. There is no sinus tenderness, and no inflammation of the upper respiratory tract mucosa can be seen.

Her blood work shows:
– Na+ 138 mmol/l
– K+ 4.3 mmol/l
– Urea 5.1 mmol/l
– Creatinine 87 µmol/l

A CT scan of her head shows no intracranial haemorrhage, mass effect, or lesions seen. However, an MRI scan shows flattening of the sclera of the eye, partially empty sella turcica, and an enlarged subarachnoid space around the oculomotor and optic nerves.

What is the likely diagnosis?