Archives: MRCP Part 2

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?

MRCP2-3264

A 36-year-old male patient complains of progressive memory impairment for the past six months. During the examination, he displays involuntary jerking movements in his limbs. The EEG results reveal biphasic high-amplitude sharp waves. What is the probable diagnosis?

MRCP2-3228

A 32-year-old woman, who is 30 weeks’ pregnant, presents to the GP complaining of her left foot dragging and tripping her up, particularly when she walks up stairs. Previously her health has been very good, with only mild allergies managed with loratadine.
On examination she looks well, with a BP of 110/70 mmHg; neurological examination reveals mild foot drop consistent with a left common peroneal nerve palsy.
Investigations reveal the following:

Haemoglobin (Hb) 120 g/l 130–170 g/l
White cell count (WCC) 6.2 × 109/l 4.0–11.0 × 109/l
Platelets (PLT) 250 × 109/l 150–400 × 109/l
Sodium (Na+) 142 mmol/l 135–145 mmol/l
Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
Creatinine (Cr) 75 μmol/l 50–120 µmol/l
Erythrocyte sedimentation rate (ESR) 8 mm/hour < 10mm/hour
C-reactive protein (CRP) < 5 mg/l < 10 mg/l
ANCA Negative
Which of the following is the most appropriate management step for this patient?

MRCP2-3229

A 42-year-old woman arrives at the Emergency Department in the early hours of the morning with a 2-week history of progressive weakness in her arms and legs, preceded by a tingling sensation in her hands and feet. She describes the weakness as ‘slowly taking over me’. Over the last day, she has also noticed weakness in her face and difficulty making facial expressions. She reports experiencing shortness of breath, slurred speech, and difficulty swallowing food. She recently returned from a 3-month trip to South America and Africa, during which she had several episodes of diarrhea. The last episode occurred about 5 weeks ago, and she noticed blood in her stool. She has no significant medical history and is not taking any regular medications.

During the examination, she displays bilateral lower motor neuron VII nerve weakness and dysarthria. Her neck is weak, but there are no other significant cranial nerve signs. She has reduced power, particularly distally, with decreased ankle and knee jerks bilaterally. Plantar responses are absent. Sensory examination reveals decreased soft touch and pinprick sensation in her hands and feet.

What is the most appropriate initial management step?

MRCP2-3230

A 63-year-old man, who is right handed, was brought to the Emergency department after collapsing at home. He has a history of hypertension but has not been compliant with therapy. Upon examination, his Glasgow coma scale (GCS) score was 15/15 and his blood pressure was 142/95 mmHg. He had significant weakness on his right side, with a grade 1/5 in his upper and lower limbs and an extensor right plantar response. A CT scan of his head revealed a left intracerebral frontoparietal haematoma. Two hours after his admission, he remained stable.

What is the most appropriate management plan for this patient?

MRCP2-3231

A 45-year-old hiker presents with flu-like symptoms and a right Bell’s palsy. She is seen by his family doctor and prescribed oral corticosteroids. She has recently returned from a four-week trip to South Germany. A week later, she returns, complaining that the facial weakness is now affecting both sides of her face and she feels weakness in her right arm. On examination, she has a temperature of 37.8 °C and a blood pressure of 120/70 mmHg. Her lungs are clear, and there are no heart murmurs. Her abdomen is soft and non-tender. She has a significant right facial palsy and minor facial weakness on the left side. There is also weakness in her right arm. Routine blood tests are normal.

What is the most appropriate next step?

MRCP2-3240

You encounter a 45 year-old man who has been referred to the neurology clinic by his GP.

He reports experiencing facial pain for the past year. The pain is particularly severe when he is shaving or brushing his teeth, and he describes it as a ‘stabbing’ sensation that goes through the teeth of his upper jaw and over the right side of his face. Despite seeing multiple dentists and having several teeth removed, he has not found any relief. The pain has been progressively worsening, and whereas before it occurred in distinct episodes, it now occurs almost constantly. He has read various online sources and has become convinced that he has a brain tumor, which has caused him to become depressed and withdrawn.

His medical history includes essential hypertension, for which he takes perindopril. He also has a history of sinusitis and has undergone sinus washouts on multiple occasions. Two years ago, while on a business trip abroad, he experienced vision problems in his left eye that resolved spontaneously over a few weeks, and for which he did not seek medical attention.

Upon examination, there are no notable findings. Cranial nerve examination is mostly normal, but you observe a patch of numbness on the right cheek. Muscle strength is 5/5 in all limb groups, reflexes are normal, and plantar responses are downward. Sensation in the limbs is normal.

What is the most appropriate course of action?

MRCP2-3244

A 43-year-old male presents with weakness in his fingers and double vision, which he noticed when he repeatedly dropped his pen whilst trying to write at work. His symptoms appear to have onset over the past few days. He had a recent episode of diarrhoea and vomiting about three weeks ago. He denies any limb weakness and sensory loss. There is no back pain or palpitations. On examination, there is a 3/5 weakness in finger flexion, finger extension and wrist extension in both hands, with no fatigability. No reflexes present in the lower or upper limbs. There is no ptosis or nystagmus but reduced eye movements in all directions. His finger-nose test demonstrates reduced coordination bilaterally and the patient has too little confidence to walk. What investigation is most likely to provide a diagnosis?