Archives: MRCP Part 2

MRCP2-3276

A 65-year-old male presents to the Emergency Department with altered sensation in both hands and reduced visual acuity in the left eye. He reports that these symptoms have gradually worsened over the past week. He denies any issues with bladder or bowel function.

Upon examination, the patient is stable hemodynamically. Notably, he has a sensory loss throughout his arms and legs, but no clear sensory level. He also has brisk reflexes in both upper and lower limbs. His left eye has a visual acuity of 6/36, while his right eye has normal vision with normal visual fields.

An MRI scan reveals multiple continuous segments of inflamed spinal cord throughout the cervical region and left optic nerve inflammation. There are no cerebral lesions. The patient’s cerebrospinal fluid (CSF) studies are negative for oligoclonal bands.

What test is necessary to confirm the diagnosis?

MRCP2-3277

A 35-year-old man is brought to the Emergency department following a car accident. As the attending physician, you are asked to assess the patient.

Upon examination, the patient is alert and oriented to time, place, and person. However, he cannot recall any details about the accident except for getting into the car to attend a meeting at 9 am. According to the paramedics who responded to the emergency call, the patient was involved in a frontal car collision and was found outside the car at 9:45 am. He was initially disoriented but regained his senses after a few minutes.

The patient has only minor injuries, including superficial scratches and bruises on his face, elbows, and knees, as well as a small hematoma on his forehead. His Glasgow Coma Scale (GCS) score is 15, and he is able to move around and is eager to leave the hospital.

As the physician in charge, what would be your recommended course of action for managing this patient?

MRCP2-3278

A 73-year-old man was admitted with a cough productive of green phlegm, shortness of breath and a low-grade fever. Past medical history included Parkinson’s disease for which he was on co-careldopa and hypertension. Chest x-ray showed a right basal consolidation and he was treated for pneumonia with oral antibiotics. As a result of the pneumonia he had a poor appetite and the patient had been refusing to take his medication.

He was given intravenous fluids and encouraged to take his oral antibiotics. Over the next 1-2 days, the nurses noted that he had started to have fever spikes of greater than 38ºC, had developed a tremor and was becoming increasingly rigid, agitated and confused. His blood pressure had also been extremely variable.

What diagnostic test would help confirm the diagnosis?

MRCP2-3279

A 35-year-old man presents to his doctor with recurrent severe pain behind his right eye that has been occurring at night for the past week. He has experienced approximately eight attacks and reports that the pain lasts for about 90 minutes each time. During an attack, his right eye becomes watery and red, and he has vomited several times due to the pain. He is a smoker and drinks alcohol regularly. On examination, he appears flushed and in distress, with a right ptosis and miosis and some right conjunctival injection. His blood pressure is elevated, and his arteries are pulsatile but non-tender. Laboratory tests reveal no significant abnormalities. What is the best treatment to give during an acute episode?

MRCP2-3280

A 32-year-old woman has been referred to the first fit clinic after experiencing a seizure three weeks ago. Her boyfriend witnessed the seizure, which lasted for approximately three minutes and involved violent shaking of her arms and legs. He also noted laboured breathing, blood in her mouth, and incontinence of urine. The day before the seizure, she had consumed one bottle of champagne and felt tired before going to bed. She has a history of asthma and frequent headaches, for which she takes sumatriptan and a salbutamol inhaler as needed. She is a smoker and drinks approximately 20 units of alcohol per week. She works in publishing and holds a driving license.

On examination, her blood pressure is 120/80 mmHg, pulse is 67 beats/minute, and neurological system is normal. Investigations reveal abnormal liver function tests, with elevated gamma GT, alkaline phosphatase, and alanine aminotransferase levels.

What would be the next step in managing this patient?

MRCP2-3281

A 67-year-old man presents to the Emergency department with confusion. His wife reports that he has been acting strangely for the past two days, experiencing difficulty with his clothing and making unusual swallowing movements. He has also had several episodes of twitching in his right hand and speech impairment. The patient has a medical history of type II diabetes, hypertension, and partial epilepsy. He takes metformin, bendroflumethiazide, phenytoin, and carbamazepine regularly. He is a smoker and drinks alcohol occasionally. On examination, he appears confused with a Glasgow coma scale of 13/15. His blood pressure is elevated, and he has subtle nystagmus and increased tone in his right upper limb. Chest and cardiovascular examination reveal left basal crackles. Investigations show multiple periventricular ischaemic white matter changes on a CT scan of the brain. How would you manage this patient?

MRCP2-3254

A 42-year-old man was on a hiking trip in Canada. He woke up at four o’clock one morning with intense neck pain that spread down to his right shoulder and forearm. The next day, the pain extended to the back of his forearm. He felt otherwise fine. His symptoms disappeared after 24 hours. However, he noticed that he couldn’t lift his right arm properly a week later, and now he’s come to the Emergency Department. During the examination of his right arm, there was atrophy of the brachioradialis, biceps, and shoulder, as well as winging of the lateral aspect of the right scapula.

Which muscle weakness is most likely responsible for the scapular winging?

MRCP2-3257

A 44-year-old female presents with her third episode of diplopia in two years. Her first episode occurred 3 years ago, during which she was unable to abduct her left eye and had a left partial ptosis, which resolved after 4 weeks. Her second episode occurred 6 months ago, during which she experienced mild vertical diplopia, diagnosed by her GP as a fourth nerve palsy secondary to diabetic microvascular disease, which improved after 6 weeks.

Her medical history includes insulin dependent diabetes, with moderate control HbA1c (IFCC 39 mmol/mol), autoimmune hypothyroidism, and vitiligo. She is a non-smoker. During examination today, you note a failure of vertical upgaze in her right eye and 50% failure of adduction with a 50% partial ptosis. Both pupils were equal and reactive.

Her admission blood tests were unremarkable, and an MRI head and orbits showed no orbital or intracranial pathology. What aspect of her medical history is most likely to lead to the underlying diagnosis?

MRCP2-3258

A 25-year-old woman presented to the outpatient clinic with a complaint of mild exertional dyspnoea that had been ongoing for two months. She reported that her symptoms were more noticeable when she walked her dog in the evening, but not in the morning. Her husband had observed that she sometimes spoke with slurred speech after the evening walk and appeared depressed. She had a history of mild anxiety and depression that had been treated by her GP.

During the examination, the patient appeared anxious, but there was no palpable lymphadenopathy. Her heart sounds were normal, and her chest was clear on auscultation. Her abdomen was soft and non-tender with no palpable masses or organs. Cranial nerves were intact, and there were no abnormalities in tone, bulk, or power in her limbs. Her reflexes were brisk and symmetrical with bilateral flexor plantar responses.

What bedside test could be used to help confirm the diagnosis?

MRCP2-3259

A 29-year-old female presents to the neurology ward with double vision and muscle weakness. She reports that the weakness is worse in the evenings and is struggling to keep her eyes open. She also experiences shortness of breath, which she attributes to a recent cold. Her medical history includes type 1 diabetes and she is a smoker of 10 cigarettes per day. On examination, she has bilateral ptosis and nasal speech, and her blood pressure is 135/85 mmHg. Cranial nerve examination reveals oculoparesis on the right lateral rectus and facial muscle weakness. Upper and lower limb examinations reveal proximal weakness and impaired sensation. Blood tests show a fasting plasma glucose of 17.5 mmol/L and positive MuSK antibodies. She is started on pyridostigmine but her breathing and forced vital capacity continue to deteriorate. What is the next step in management?