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?
MRCP2-3245
A 25-year-old woman was referred to neurology clinic by her family. She has been experiencing repetitive movements of her shoulders and hands for the past year. Initially, the movements were infrequent, but now they occur every few minutes. The movements are stereotyped and involve a brief shrug of the shoulders and clapping movement of the hands. During these episodes, she remains fully conscious but sometimes mutters inappropriate words. This has caused her to lose her job and struggle in social situations. She has no significant medical history and has reached all developmental milestones. As a child, she was very organized and would arrange her toys in a specific way. She has been under a lot of stress and has lost weight in the past year. On examination, she appears anxious and continuously rubs her coat sleeve. Several movements occur affecting her shoulders and hands, lasting a few seconds. When asked about the movements, she becomes more anxious and simply states that she has to do them. Cranial nerve examination is normal, but testing power results in increased anxiety followed by multiple arm movements. Cardiovascular, chest, and abdominal examinations are all normal. A CT scan of the brain is normal. Hemoglobin, white cell count, and platelets are within normal range. Serum sodium, potassium, and urea are also within normal range. Serum copper is low, and serum caeruloplasmin is normal. Based on this clinical account and the results of the investigations, what is the likely diagnosis?
MRCP2-3246
A 63-year-old man is experiencing difficulty walking. He has a medical history of diabetes mellitus and cervical spondylosis, for which he underwent surgical decompression eight years ago. Additionally, he consumes 40 units of alcohol per week.
During examination, the patient exhibited fasciculation, wasting, and weakness in the left deltoid and biceps, as well as weakness in the shoulder girdle muscles on both sides. There was also fasciculation in the glutei and quadriceps bilaterally, weakness in hip flexion and foot dorsiflexion, brisk reflexes in the upper and lower limbs, and extensor plantar responses. No sensory impairment was detected.
What is the likely diagnosis for this patient?
MRCP2-3210
A 14-year-old boy comes to the clinic with a history of a single seizure that occurred without warning after a family gathering. Upon further questioning, he reports experiencing episodes of blank spells for the past six years and brief shock-like contractions of his upper limbs several times a month, particularly during breakfast. There are no significant medical or family histories, and physical examination is unremarkable.
Which statement about the patient’s condition is false?
MRCP2-3211
A 20 year old woman comes to the general medical clinic for evaluation. She has been referred due to drooping of her eyelids, first on the left and now bilaterally. Upon further questioning, she reports difficulty reading in low light and mentions that two family members have had to undergo cardiac pacemaker placement. During the examination, partial bilateral ptosis and a generalized ophthalmoplegia in all directions of gaze are observed. Fundoscopy reveals central areas of dark pigmentation on a pale fundus.
Which investigation is most likely to lead to a diagnosis?
MRCP2-3212
You are presented with a 19-year-old female who has limited eye movements and progressive muscle weakness. When she was 7 years old, she experienced double vision that eventually resolved. However, in her early teens, she found it difficult to keep up with other children during playtime. Over the past year, her double vision has returned and she has noticed a gradual weakening of her muscles, making it challenging to stand up from a seated position.
During the examination, you observe that she is of short stature and has ptosis, as well as a lack of spontaneous facial expressions. Her mental status examination is normal, but her eye movements are absent in all directions. Her pupils respond to light, but her visual acuity is reduced even with correction. The fundi show pigmentary degeneration, but there are no cataracts present. Her hearing is normal.
Upon conducting a motor examination, you discover that she has weak neck muscles and proximal muscle groups in her lower extremities. Her deep tendon reflexes are reduced, and her plantar reflexes are flexor. Cerebellar testing reveals intact finger to nose, slow rapid alternating movements in the upper extremities with mild ataxia, moderate heel to shin ataxia, and gait ataxia. Romberg’s testing is steady with eyes open and closed. Sensory examination shows preserved sensation to all primary modalities. The rest of the systemic examination is unremarkable, but her ECG shows incomplete heart block.
Which diagnostic test would be the most beneficial in establishing a diagnosis?
MRCP2-3213
A 55-year-old man with learning difficulties presents with urinary incontinence and difficulty managing household tasks. He has a history of losing his son to multiple sclerosis. On examination, he has poor short and long term memory, labile affect, and difficulty interpreting proverbs. He also exhibits horizontal nystagmus, past-pointing in the upper limbs, and difficulty with heel-to-toe walking in the lower limbs. Brisk deep tendon reflexes and extensor plantar responses are present. What is the probable diagnosis?
MRCP2-3214
A 55-year-old man with learning difficulties presents with urinary incontinence. He lives alone and has been struggling with simple household tasks like cooking and cleaning for the past two months. He reports difficulty with concentration and memory. His son passed away from complications of multiple sclerosis.
During examination, he was oriented in time, place, and person but had difficulty with recall and long-term memory. He also had labile affect and difficulty interpreting proverbs. Cranial nerve examination was unremarkable except for bilateral horizontal nystagmus on lateral gaze. Limb examination revealed past-pointing in the upper limbs, difficulty with heel-to-toe walking in the lower limbs, brisk deep tendon reflexes, and extensor plantar responses. Bilateral palmomental reflexes were present.
What treatment plan would you recommend for this patient?
MRCP2-3225
A 35-year-old woman presents to the neurology clinic with flu-like symptoms, double vision, and facial weakness that have been ongoing for four days. She reports experiencing double vision when looking to the right and is unable to fully close her eyes. The patient recently returned from a camping trip in the New Forest six weeks ago. She has a medical history of type I diabetes, which was diagnosed when she was eight years old, and takes regular insulin injections.
During the examination, the patient appeared alert and oriented. She complained of arthralgia in her hands and knees. Her blood pressure was 130/75 mmHg, pulse was 70/min and regular, temperature was 37.4°C, and blood glucose monitoring was 4.7 mmol/L. There was no evidence of rash or neck stiffness.
On cranial nerve examination, fundoscopy was normal, and both pupils were equal and reactive to light. Ocular movement testing revealed oculoparesis of the right lateral rectus. Bilateral facial weakness with bilateral Bell’s phenomenon was also observed. Examination of the peripheral nervous system did not reveal any abnormalities.
A lumbar puncture was performed, and the results showed an opening pressure of 13 cmH2O (5-18), CSF protein of 1.3 g/L (0.15-0.45), CSF white cell count of 120 per ml (<5), CSF white cell differential of 90% lymphocytes, CSF red cell count of 4 per ml (<5), and CSF glucose of 3.9 mmol/L (3.3-4.4). CSF oligoclonal bands were present, while serum oligoclonal bands were negative.
An MRI scan of the brain revealed multiple periventricular white matter lesions. Based on the patient’s history and clinical findings, what would be the appropriate management plan?
MRCP2-3226
A 63-year-old man presents to the Emergency department with sudden onset right-sided weakness lasting approximately 20 minutes. He had a similar episode the week before lasting approximately 10 minutes. He is a smoker of 15 cigarettes/day and takes bendroflumethiazide 2.5 mg/day for hypertension. On examination, his blood pressure is 140/98 mmHg, pulse is 65 and irregularly irregular, and heart sounds are normal. He has a left carotid bruit. A CT scan with contrast did not show any abnormalities. Investigations reveal a 75% stenosis of the left external carotid artery. Which of the following options offer the best way of managing this patient?