Archives: MRCP Part 2

MRCP2-3304

A 65-year-old man with a history of Type 2 diabetes for the past 10 years presents for a check-up. He is currently managing his diabetes with BD mixed insulin and has been experiencing increasing pins and needles and pain in both feet over the past year. In addition to his diabetes, he has a history of a previous myocardial infarction and intermittent urinary retention over the past year, which has been diagnosed as benign prostatic hypertrophy by his GP. On examination, his blood pressure is 150/85 mmHg, his pulse is regular at 75 beats per minute, and he has peripheral neuropathy affecting both feet, which are numb up to the ankle. Routine blood tests, including renal function, are normal.

What is the most appropriate course of action for this patient?

MRCP2-3305

A 70-year-old man presents to the neurology outpatient department with a gradual onset of tremor as referred by his primary care physician. He has a medical history of hypertension and recurrent falls and is currently taking amlodipine. He denies smoking or alcohol consumption.

During the examination, the patient displays bradykinesia and rigidity, along with a pill-rolling tremor in his right hand. He is unable to perform vertical saccades with his eyes and appears to lean forward while walking.

What is the probable diagnosis?

MRCP2-3306

A 78-year-old male has been referred to your Parkinson’s disease clinic by his GP. The patient and his wife have reported an increase in falls, with the most alarming incident occurring last week when he fell down 4 steps of stairs, fortunately without any lasting harm. During the examination, you observe a slow pill rolling tremor present on both hands and bilateral cog-wheeling. The patient’s cranial nerves appear normal, except for a lack of upwards gaze. His speech is clear but has a nasal quality. What is the most probable diagnosis?

MRCP2-3307

A 26-year-old woman visits her doctor with complaints of frequent headaches, happening 2-3 times a month. The headaches last for about 5 hours and are accompanied by a throbbing sensation, photophobia, phonophobia, nausea, and a visual aura. There is no specific pattern to when the headaches occur. She has no medical history and is not taking any regular medications.

During the examination, her body mass index is found to be high (34 kg/m²). Her neurological examination is normal, and she is currently not experiencing any headaches.

What is the most appropriate medication to prevent further headaches, given the likely diagnosis?

MRCP2-3308

A 36-year-old woman presents to the Emergency department after experiencing a loss of consciousness while shopping. Her friend who was with her witnessed the episode and described her as becoming anxious, breathing rapidly, and then suddenly collapsing and shaking her arms and legs. Upon admission, she was still experiencing violent limb shaking and had also involuntarily urinated. She has a history of anxiety and depression but does not take any regular medication. She smokes 20 cigarettes per day and drinks 14 units of alcohol per week. On examination, her blood pressure is 140/80 mmHg, pulse is 92 beats per minute and regular, temperature is 36.8°C, and oxygen saturation is 99% on room air. Her eyes are tightly shut and impossible to open passively, and she is violently shaking both arms and legs. Plantar responses are flexor.

What is the most appropriate management for this patient based on her history and clinical findings?

MRCP2-3309

A 50-year-old man presents to his GP with sudden onset left-sided blurred vision and a history of bumping into things on his left side, leading to falls. He denies any pain in the left eye or associated headache and reports no weakness or sensory disturbance in his arms or legs. He has no known medical conditions but is being investigated for an isolated seizure and memory difficulties. He is a non-smoker and works on a cattle farm.

On examination, the patient has yellowish papules on the neck, and his blood pressure is 140/80 mmHg with a regular pulse of 72 beats per minute. Corrected visual acuity is 6/9 in the left eye and 6/6 in the right, with a left relative afferent pupillary defect. Fundoscopy reveals some pallor of the left optic disc and angioid streaks, and visual field testing shows a left homonymous hemianopia. The rest of the cranial nerve examination and peripheral nervous system examination are normal.

Investigations reveal normal electrolytes, urea, creatinine, glucose, and cholesterol levels, with an erythrocyte sedimentation rate of 15 mm. A transthoracic echocardiogram is normal. An MRI brain and orbits (FLAIR) show multiple bilateral ischemic infarcts in the brain and a large right parieto-occipital infarct, with normal orbits and optic nerves.

What is the most likely diagnosis?

MRCP2-3310

A 50-year-old male presents with a 4-week history of speech slurring, dysphagia and droopiness of his eyelids. He has a past medical history of well-controlled type 2 diabetes mellitus and hypertension. Upon examination, bilateral ptosis is noted with a full range of eye movements. The patient’s speech begins to slur at 15 when asked to count upwards. During the examination, he spits out upper airway secretions three times but is able to swallow half a glass of water. The neurological examination of the rest of his cranial nerves, upper and lower limbs are unremarkable. The FVC is 85% of predicted. What is the most appropriate treatment?

MRCP2-3311

A 32-year-old man visits his doctor, feeling very distressed. He woke up that morning with a sensation that his right cheek was feeling heavy. He immediately saw himself in the mirror and was horrified to find that his face was twisted. He could not close his right eye. Saliva drooled from the angle of his mouth on the right side. He was extremely distressed to note that when he tried to smile his mouth deviated to the left side. There is some sense of dizziness and hearing is muffled on the right side. His father had had a stroke 4 weeks ago. The only medication of note is the antihypertensive medication.

On examination, his blood pressure is 150/80 mmHg, his pulse is 80/min and he is anxious. Examination of his right ear reveals a few tense vesicles in his right ear and there is right-sided facial nerve palsy.

What is the most likely diagnosis?

MRCP2-3312

A 70-year-old man presents with transient expressive dysphasia and clumsiness in his right hand, which resolved after 20 minutes. He has no history of ischaemic heart disease or diabetes, but he is an ex-smoker with a 50 pack year history. His blood pressure is 160/70 mmHg, and he is in sinus rhythm. Neurological examination reveals no detectable signs.

An MRI brain scan shows a small area of restricted diffusion in the left frontotemporal region, indicating ischaemia. The patient’s total fasting cholesterol is 4 mmol/L (normal), with an LDL level of 2.5 mmol/L (normal). Besides dietary advice and exercise, what other interventions may benefit this patient in terms of his cholesterol levels?

MRCP2-3313

A 40-year-old woman with no significant medical history presents with fatigue and lethargy that have persisted for several years. She reports difficulty sleeping at night and experiences discomfort in her lower extremities at rest, particularly when trying to fall asleep. She also describes an abnormal crawling and itching sensation below the knees that is relieved by walking. There is no history of pain or snoring at night. Despite several tests ordered by her general practitioner, including brain imaging, thyroid function, and haemoglobin monitoring, all results have been normal. She is not taking any medications and is now working part-time due to her symptoms. What treatment would you recommend to alleviate her symptoms, given the likely underlying diagnosis?