Archives: MRCP Part 2

MRCP2-3252

A 50-year-old female presents to the neurology clinic with complaints of fatigue and muscle weakness, specifically in the lower limbs, which is causing difficulty walking. The patient has experienced similar episodes in the past, with one episode resulting in painful, reduced visual acuity. These episodes typically last a few weeks before resolving on their own.

During the examination, the patient exhibits spasticity weakness in the lower limbs with reduced sensation distally. Cranial nerve and spinal examinations are normal. An MRI of the brain reveals disseminated brain lesions, and further testing confirms unpaired oligoclonal bands in the CSF, but not in the serum.

Which of the following factors is associated with a poor prognosis in the patient’s most likely diagnosis?

MRCP2-3253

A 63-year-old man presents to neurology with a tremor affecting both arms, slow activities, and recent balance issues. He also reports urinary incontinence and erectile dysfunction. His medical history includes hypertension, myocardial infarction, and hypercholesterolaemia, and he takes ramipril, bisoprolol, aspirin, and simvastatin. On examination, he has increased tone and impaired coordination. His blood tests show a low TSH and high creatinine. What is the most likely cause of his symptoms?

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?

MRCP2-3260

A 32-year-old woman is referred by her GP for neurological evaluation of muscle weakness and stiffness. Her mother also had similar problems and had died due to respiratory failure. She also gives a history of progressive visual impairment of a few years’ duration. The other problem is recurrent dislocation of her shoulder. She is a known diabetic on insulin and has recently attended the endocrinologist for evaluation of infertility.

On examination, she has bilateral cataracts, bilateral mild ptosis is evident and there is frontal balding. Ocular movements are normal but there is wasting of the temporalis, masseter and sternocleidomastoid muscles on both sides. Muscles of both hands are wasted and both wrists are weak. When you shake her hand she can only slowly relax her grip. There is bilateral foot drop and tendon reflexes are reduced.

What is the most likely diagnosis for this patient?

MRCP2-3261

A 38-year-old woman has been diagnosed with relapsing remitting multiple sclerosis and is exploring further treatment options, including natalizumab. Despite receiving glatiramer acetate, she has experienced two severe relapses. Although she is still able to work, she feels fatigued and has limited mobility.

During her examination, the woman displays brisk reflexes bilaterally, with mild weakness in her proximal left leg and reduced sensation in her left foot. Her brain MRI reveals highly active disease with multiple acute and subacute plaques, as well as a single lower cervical cord lesion.

Before considering a new therapy, which investigation result is of the utmost importance, aside from HIV and general immunological status?

MRCP2-3262

A 25-year-old female with multiple sclerosis (MS) presents to the emergency department after experiencing a seizure. She was diagnosed with MS at age 20 and has been on various immunomodulatory treatments, including azathioprine. She started natalizumab therapy 3 years ago. This is her first seizure, but she reports feeling increasingly clumsy over the past 8 months and has had several instances of slurred speech where people have commented that she sounds tired.

During the examination, her muscle tone is normal, and she has normal power in all muscle groups in both upper and lower limbs. However, a right homonymous superior quadrantanopia is identified, although she has full eye movement and no ptosis. She also has an ataxic gait, but her speech is normal.

The patient is worried and asks for a diagnosis. What is your assessment?

MRCP2-3263

A 28-year-old woman presents to her GP with complaints of experiencing tunnel vision episodes. These episodes occur while she is at work and are preceded by dizziness and fatigue. The tunnel vision lasts for several minutes and is sometimes accompanied by dark holes in her visual range. After an episode, she feels anxious and develops a headache. She has had approximately six episodes in the past month.

The patient has a medical history of type 1 diabetes, which is controlled with TDS insulin. She takes co-codamol for headaches and has a family history of glaucoma. She is a smoker and drinks approximately 20 units of alcohol per week. She works as a legal secretary and admits to experiencing work-related stress.

During the examination, her blood pressure was 139/89 mmHg, and her pulse was 89 beats per minute. Fundoscopy revealed scattered cotton-wool spots, and there were no other cranial nerve abnormalities. Her peripheral nervous system examination was normal, except for some diminished pin prick sensation over the dorsum and soles of both feet.

Investigations revealed a glucose level of 8.9 mmol/L (3.0-6.0) and an HbA1c level of 74 mmol/mol (<42) or 8.9% (<6%). An electrocardiogram showed a heart rate of 88 beats/min in sinus rhythm. What is the most likely cause of this patient’s symptoms?