Archives: MRCP Part 2

MRCP2-3291

A 58 year-old consultant surgeon has recently been diagnosed with idiopathic Parkinson’s disease and is attending clinic for review. The previous clinic letter shows that he presented with a tremor affecting mainly the right hand, which forced him to stop operating. On examination, he also had some bradykinesia and rigidity of the right hand. He was started on co-beneldopa 100/25, initially one tablet three times daily, with instructions to up-titrate as tolerated.

During today’s visit, the surgeon expresses concern that there has been no improvement in the tremor. This is causing him considerable distress as he hopes to return to clinical work. Although his motor control is otherwise good, and he has no difficulty with ‘off’ periods or freezing throughout the day and night, he currently takes co-beneldopa 100/25, two tablets three times daily, and reports no complications.

On examination, there is a resting tremor of the right hand, but no discernable rigidity or bradykinesia. What is the best treatment option?

MRCP2-3292

A 68-year-old male arrives at the hospital with sudden onset of right-sided weakness and speech impairment that has lasted for two hours. A CT cerebral angiogram reveals thrombosis in the proximal left middle cerebral artery (LMCA). The patient had undergone laparotomy for bowel obstruction caused by an incarcerated umbilical hernia seven days prior to this incident. In the absence of IV thrombolysis, what emergency treatments could potentially help this patient?

MRCP2-3293

A 38-year-old male presented with a 6-month history of weakness affecting his upper limbs. He found that this was worse at the end of the day, particularly if he had been doing a lot of lifting. He also reported occasional difficulty in swallowing at the end of the day, with drinks causing him to cough. He had been prescribed pyridostigmine, but he stopped taking this as he had not noticed any benefit.

On examination, there was a mild partial ptosis, and a slight facial droop bilaterally. Extra-ocular movements were normal. Power in shoulder abduction was grade 4/5 bilaterally, but was reduced to 3/5 after repeatedly abducting and adducting the shoulder 20 times. Tone and sensation were normal.

Initial investigation results are shown below:

Nerve conduction studies: Decremental response to repetitive nerve stimulation
Single-fibre electromyography: Increased jitter
Anti-Jo antibodies: Negative
Anti-Mi2 antibodies: Negative
Anti-acetylcholine receptor antibodies: Negative

Which of the following immunological tests is most likely to contribute to the diagnosis?

MRCP2-3294

A 67-year-old man experiences left-sided hemiparesis and facial droop while shopping with his wife at 2:35 pm. A CT head scan is performed at 3:40 pm, which shows no intracranial haemorrhage or space occupying lesion. At 3:50 pm, he receives alteplase in the emergency department.

The next day at 9:00 am, a post-thrombolysis CT head reveals a right middle cerebral artery infarction with no evidence of intracranial haemorrhage or haemorrhagic transformation. An ECG done in the stroke unit shows atrial fibrillation with a heart rate of 110 beats per minute. He continues to have dense left-sided weakness several hours after thrombolysis.

What medication should be added to his treatment plan?

MRCP2-3295

A 65-year-old man came to the neurology clinic for evaluation. He had been experiencing progressive motor neuron disease for the past five years, resulting in significant weakness in all of his limbs and reliance on a wheelchair. He was taking baclofen for muscle spasms and amitriptyline to reduce salivation, but no other medications. He reported experiencing morning headaches that were throbbing in nature and not feeling refreshed after sleep.

During the examination, the patient exhibited general muscle wasting and fasciculations in all limbs. Reflexes were absent except for bilateral extensor plantar responses. Eye movements and fundoscopy were normal, and there were no significant issues with palatal movements or swallowing.

What intervention would likely provide the greatest survival benefit for this patient?

MRCP2-3296

A 67-year-old woman was admitted to a gynaecology ward for repair of a cervical prolapse. The operation went smoothly and she was up and about within two days. However, on the fifth day after surgery, she was found wandering in a confused state in the adjacent ward. She had been complaining of a throbbing headache for the past hour, but had otherwise been feeling fine. The confusion lasted for about two hours, during which she repeatedly asked, What am I doing here? She had no memory of the episode afterwards, but was able to resume normal conversation, although she needed to be reminded how long she had been in the hospital.

The patient had a medical history of hypertension, hyperlipidaemia, and migraine. She took regular atenolol and simvastatin, did not smoke, and did not drink alcohol. There was no family history of medical problems. On examination, she complained of a headache, but her vital signs were normal. Cranial nerve examination was normal, and there was no evidence of nystagmus. Peripheral nervous system examination, including plantar reflex responses, was normal. Chest and cardiovascular examination were entirely normal.

Investigations revealed a haemoglobin level of 112 g/L (normal range: 130-180), a white cell count of 11.3 ×109/L (normal range: 4-11), platelets of 245 ×109/L (normal range: 150-400), an ESR (Westergren) of 18 mm/1st hour (normal range: 0-15), a serum sodium level of 136 mmol/L (normal range: 137-144), a serum potassium level of 4.5 mmol/L (normal range: 3.5-4.9), a serum urea level of 4.2 mmol/L (normal range: 2.5-7.5), a serum creatinine level of 89 µmol/L (normal range: 60-110), a serum C reactive protein level of 15 IU/L (normal range: <5), and a urinalysis showing protein ++ and blood +. Based on the clinical account and investigations, what is the most likely diagnosis for this patient?

MRCP2-3297

An 80-year-old woman visits her GP with patchy dysesthesia affecting her feet bilaterally. She denies any back pain and reports no recent changes in her bowel habits. She experiences stress incontinence, but her urinary symptoms have not changed recently. Upon examination, there is no weakness, and reflexes are intact. Her medical history includes hypertensive nephropathy and diet-controlled type 2 diabetes. She takes amlodipine 10mg, ramipril 5mg, and bendroflumethazide 2.5mg for her hypertension, and for the past year, nitrofurantoin 100 mg as prophylaxis for urinary tract infections.

Na+ 135 mmol/l
K+ 4.2 mmol/l
Urea 10.8 mmol/l
Creatinine 186 µmol/l
Glucose 8.3 mmol/l

What is the most probable cause of her symptoms?

MRCP2-3298

A 60-year-old man presents to you after being diagnosed with Parkinson’s disease by a specialist in secondary care. His condition has worsened over the past year and a half, leading to significant functional disability. He has been advised by his Parkinson’s disease specialist nurse to consider drug treatment and has an upcoming appointment with his consultant to discuss this. However, he is confused about the different types of drugs available and wants to know the likely options. What class of drug would be appropriate for initial pharmacotherapy in this patient?

MRCP2-3299

A 25-year-old man is brought to the Emergency Department by his friends as they have noticed him acting strangely over the last 6 months. His friends are particularly concerned about his excessive drinking and going out without informing them. They have also noticed his walking has become progressively more unsteady and he often slurs his speech. His mother has a history of depression and his father has a history of seizures.

On examination, he has coarse nystagmus to lateral gaze bilaterally, slurred speech, and an ataxic gait. The rest of his neurological examination is normal.

What is the most likely diagnosis?

MRCP2-3273

A 65-year-old man presents with a six month history of progressive unsteadiness. He reports an irregular swaying gait with a tendency to veer to the left when walking. His wife notes that he stands with his feet apart. He also complains of urinary urgency and frequency, despite multiple negative urine tests. He attributes occasional muscle stiffness to aging.
On examination, his pulse is 70 beats/min, BP 135/80 mmHg supine, 105/55 mmHg standing. There is increased tone in opposing muscle groups when joints are passively moved, but no muscle wasting or weakness. Gait is broad-based with a leftward lean. Reflexes are brisk and plantar responses are downgoing bilaterally. Finger to nose testing is impaired in the upper limbs. Sensory exam is normal.
What is the likely diagnosis?