Archives: MRCP Part 2

MRCP2-3314

A 75-year-old male presents to his GP complaining of a crawling sensation in his legs and an urge to move them, especially at night. These symptoms have been present for six months and have worsened over the last two months, causing daytime sleepiness. The patient has a history of hypertension, which is managed with atenolol and ramipril. He quit smoking 10 years ago and drinks 20 units of alcohol per week. He lives alone and has limited family support.

During examination, the patient’s blood pressure was 158/88 mmHg, pulse was 80/min and regular, and heart sounds were normal. Scratch marks were observed on his lower limbs, but tone, power, and reflexes appeared normal with flexor plantar responses. All pulses were present and easily palpable, and abdominal examination was normal.

Investigations revealed a haemoglobin level of 101 g/L (130-180), mean cell volume of 72 fL (80-96), white cell count of 9.2 ×109/L (4-11), and platelets of 285 ×109/L (150-400). Serum sodium was 138 mmol/L (137-144), serum potassium was 4.2 mmol/L (3.5-4.9), serum urea was 5.1 mmol/L (2.5-7.5), serum creatinine was 90 µmol/L (60-110), fasting plasma glucose was 4.5 mmol/L (3-6), and serum cholesterol was 5.1 mmol/L (<5.2). What would be the appropriate management plan for this patient?

MRCP2-3315

A 20-year-old female presents to the Emergency Department after experiencing a seizure. She has no significant medical history but has been complaining of a severe headache for the past few hours. On examination, she appears confused and is holding her head in her hands. Her GCS is 13/15 (M6 V4 E3), and there are no focal neurological deficits. Her pulse rate is 90/min, and she has a temperature of 37.2º. No neck stiffness is noted. A CT scan with contrast is ordered. What is the most likely diagnosis?

MRCP2-3316

A 57-year-old Asian woman came to the clinic with a gradual onset of difficulty swallowing and hoarseness for the past year. She also reported a persistent dry cough for the past two years. Upon examination, she had nasal-sounding speech, reduced left-sided gag reflex, weakened palate, and left-sided tongue atrophy with deviation to the left. All other cranial nerves were normal, and there were no abnormalities in her limbs. What is the probable diagnosis?

MRCP2-3320

A 22-year-old woman is suffering from treatment-resistant depression. Despite being under the care of psychiatrists for two years and trying various anti-depressants, her symptoms remain uncontrolled. She was recently started on moclobemide four days ago.

During examination, she appears acutely unwell, confused, and tremulous. Her temperature is 39°C and her blood pressure is 155/100 mmHg. Although her chest, heart, and abdomen appear normal, she has rigidity with greatly increased tone in all limbs and ankle clonus. A septic screen came back negative.

What is the most likely diagnosis?

MRCP2-3324

A 73-year-old man presents to the oncology team with progressive lower thoracic back pain over the past three weeks. The pain has now reached an intensity that has prevented him from sleeping during the past two nights, despite over the counter analgesics. What investigations are appropriate for his back pain?

MRCP2-3325

A 30-year-old woman visits her GP with complaints of difficulty climbing stairs at home. She mentions that her mother passed away in her early 50s due to severe pneumonia, and had trouble breathing and had to sleep propped up for several months before her death. The patient reveals that her parents were first cousins. She also reports struggling with exercise and sports during her school years and currently has a sedentary job in an office.
During the examination, the GP observes proximal weakness in her legs with lower motor neurone signs. There is mild upper limb weakness, but it is not as severe as in the lower limbs.
What is the most probable diagnosis?

MRCP2-3326

A 57-year-old woman presented to the hospital with symptoms of sweating, nausea, palpitations, and intermittent crawling sensations in her hands and feet spreading up her arms and legs. She had recently visited her GP due to severe nausea and vomiting, and as a result, her GP had stopped all her medications. The patient had a medical history of hyperthyroidism, anxiety, depression, and atrial fibrillation, for which she was taking carbimazole, propranolol, paroxetine, amiodarone, and aspirin. Within two days of stopping her medications, she developed the aforementioned symptoms, along with anxiety, erratic behavior, and vivid dreams. On examination, her blood pressure was 140/78 mmHg, pulse was 97/min and irregularly irregular, and neurological examination revealed poor attention and concentration. Investigations showed abnormal levels of haemoglobin, white cell count, and serum potassium. Based on this information, which medication withdrawal is likely responsible for the patient’s symptoms?

MRCP2-3327

A 48-year-old woman presented to the general medical clinic with a complaint of progressive diffuse myalgia and weakness that had been ongoing for three months. She reported experiencing difficulty walking up and down stairs due to weakness in her shoulder muscles and thighs. Her medical history included hypertension and hyperlipidemia, for which she took atenolol and simvastatin regularly. On examination, there were no abnormalities in the cranial nerves or detectable neck weakness. However, there was general myalgia in the upper limbs and proximal weakness of 3/5 with preserved distal power. A similar pattern of weakness was observed in the lower limbs with preserved tone, reflexes, and sensation.

The following investigations were conducted: haemoglobin, white cell count, platelets, ESR (Westergren), serum sodium, serum potassium, serum urea, serum creatinine, plasma lactate, serum creatine kinase, fasting plasma glucose, serum cholesterol, plasma TSH, plasma T4, and plasma T3. Urinalysis was normal.

Based on these findings, what is the likely diagnosis?

MRCP2-3328

A 25 year-old individual with epilepsy is admitted to the hospital with generalised tonic-clonic status epilepticus. The patient is currently on phenytoin. Despite receiving intravenous diazepam and phenobarbital, the seizures continue after 30 minutes.

What would be the most appropriate next step in managing this patient’s condition?

MRCP2-3329

A 35-year-old Nigerian woman was referred for evaluation of progressive weakness and tingling in her lower limbs over the past 5 months. She has also noticed a decline in her vision and difficulty hearing the television. She is currently unemployed and struggling financially.

During examination, she had excoriations around the mucocutaneous junction of her mouth. Fundus examination revealed pale optic discs on both sides. Rinne’s test showed air conduction to be better than bone conduction. Audiogram revealed that she could hear 8000 Hz at 60 decibels and 250 Hz at 20 decibels.

The distal groups of muscles in all limbs were weak with 4/5 power, and tendon reflexes were reduced. Romberg’s test was positive.

What is the most likely diagnosis?