Archives: MRCP Part 2

MRCP2-3217

A 67-year-old man presents to a neurologist with weakness in his left foot. He reports stubbing his toes while walking and experiencing numbness in his entire left foot and up the back of his thigh. He denies any back pain or issues with bowel or bladder function. The patient has a history of diabetes and hypertension and takes metformin, gliclazide, and ramipril. He also smokes 10 cigarettes per day and drinks four pints of beer on the weekends.

On examination, there is evidence of wasting in the left anterior compartments of the lower leg and mild wasting of the hamstrings. The left ankle has significantly reduced tone and the left foot has flaccid tone. The patient exhibits marked weakness in foot dorsiflexion, plantar flexion, eversion, and inversion, as well as additional weakness in left hip extension and knee flexion. There is an absent ankle and plantar response on the left with all other reflexes intact. Sensory examination reveals reduced sensation to all modalities over the entire posterior left lower leg and the back of the left thigh.

What is the likely location of the lesion in this patient?

MRCP2-3218

A patient suffering from focal epilepsy that is not responding to two medications is prescribed levetiracetam. What is the most crucial adverse effect that patients starting this medication should be cautioned about?

MRCP2-3219

A 50-year-old woman has experienced weight loss over the past six months. Her family has noticed that she has become forgetful over the last two months, struggling to remember things like phone numbers or her daily activities. She has recently had a second episode of what appears to be a generalized tonic-clonic seizure within the last week. She has no significant medical history. Upon examination, she has a MMSE score of 23/30, appears cachectic, has a bulky left adnexal region, and no other notable findings. Routine blood tests are normal. A CT scan of the chest, abdomen, pelvis, and head reveals a suspicious lesion in the left ovary but is otherwise unremarkable. A biopsy of the left ovary is ordered, along with a paraneoplastic blood screen and an MRI of the brain. What results would you anticipate from the paraneoplastic screen?

MRCP2-3220

A 40-year-old man presents to the hospital with sudden onset quadriparesis and complete loss of speech. His partner reports that he had been feeling well prior to the event and had not complained of any symptoms. The patient has a history of frequent cocaine use and occasional heroin injection. On admission, he has a Glasgow coma scale of 3/15 and pinpoint pupils with oculoparesis. Neurological examination reveals generalised hypertonia and hyperreflexia with bilateral extensor plantar responses. He is intubated and taken to intensive care. After four weeks of extensive investigation, he regains consciousness but exhibits decerebrate rigidity and is unable to speak or make any purposeful response. What is the most likely cause of his condition?

MRCP2-3221

A 55-year-old man presents to the emergency department with a 2-day history of bilateral leg weakness. He is having difficulty standing up from a chair and has also noticed finger paraesthesia.

The patient has no significant medical history, but reports recent diarrhoea. He is a smoker and drinks up to 4 pints of beer most nights. He works as a plumber.

On examination, there is marked weakness in the lower limbs, absent reflexes, and dysarthria. A bedside swallow assessment reveals significant coughing. An MRI of the whole spine is normal, but blood tests show a raised ALT.

Assuming standard treatment, what is the likelihood of long-term weakness given the likely diagnosis?

MRCP2-3222

A 50-year-old man with a history of hypertension and ischemic heart disease presents to the emergency department after collapsing. He experienced weakness on his left side before suddenly falling to the ground. His partner reports that he was unconscious for approximately two minutes and noticed that the right side of his face drooped. However, the patient’s symptoms resolved entirely after an hour.

Given the patient’s medical history and symptoms, what aspect of his history indicates that an alternative diagnosis is more probable than a TIA?

MRCP2-3223

A 26-year-old woman presents to the neurology outpatient clinic with a history of idiopathic intracranial hypertension and recurring headaches. She is currently taking acetazolamide. Upon examination, papilloedema is observed during fundoscopy, and her body mass index is 31 kg/m². Her visual acuity is normal. To address her condition, a therapeutic lumbar puncture is performed in the left lateral position, during which 10 ml of cerebrospinal fluid is removed and an opening pressure of 29  25 cmCSF is recorded. Unfortunately, the patient develops a headache following the procedure. What could have been done to reduce the likelihood of this complication?

MRCP2-3224

A 65-year-old man presented to the Emergency department with weakness and excruciating pain in his right lower limb. The weakness and pain had progressively worsened over several weeks, to the point where he was wheelchair bound. He did not complain of any back pain, but had noticed increased urinary frequency and hesitancy.

He had a medical history of diabetes and hypertension, and regularly took metformin and ramipril. He was a smoker of 20 cigarettes per day and drank six units of alcohol per week.

On examination, he appeared in some distress. There was evidence of right leg oedema, and the leg itself appeared warm and dry to touch. Tone was diminished at the hip, knee, ankle, and foot, and there was evidence of wasting over the anterior and posterior compartments of the right lower leg. There was 3/5 power of hip flexion, extension, and adduction, with marked weakness of knee flexion, dorsiflexion, plantar flexion, eversion, and inversion. The knee, ankle, and plantar reflexes were all absent. On testing sensation, there was diminished pinprick over the toes, extending to the perianal area in the right leg. The left leg appeared normal.

Investigations revealed:

– Haemoglobin 125 g/L (130-180)
– White cell count 11.1 ×109/L (4-11)
– Platelets 345 ×109/L (150-400)
– Serum sodium 134 mmol/L (137-144)
– Serum potassium 3.5 mmol/L (3.5-4.9)
– Serum urea 6.7 mmol/L (2.5-7.5)
– Serum creatinine 123 µmol/L (60-110)
– Serum corrected calcium 3.1 mmol/L (2.2-2.6)

What is the most likely diagnosis?

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?