Archives: MRCP Part 2

MRCP2-3227

A 68-year-old right-handed man is referred to the Stroke Unit. He is a lifelong heavy smoker but has no past medical history. He reports sudden onset facial paralysis that has persisted for a day. He also notes that sounds seem louder on the left side.

Upon examination, there is flattening of the nasolabial fold on the left, and he is unable to raise his eyebrow or close his eye on that side. His blood pressure is 160/80 mmHg. There is no rash or adenopathy. The rest of his neurological examination, including auroscopy, assessment of parotids and mucous membranes, is normal.

What is the most appropriate management plan for this patient?

MRCP2-3201

A 55-year-old man was admitted to a tertiary referral center with severe right-sided weakness and a Glasgow Coma Score of 8. The onset of symptoms was estimated to be 6 hours prior to admission. The patient exhibited bilaterally up-going plantar responses and had no major co-morbidities. A CT scan of the brain revealed a significant area of infarction within the territory of the left middle cerebral artery, accompanied by massive cerebral edema and midline shift. What interventions may be beneficial for the patient during the acute phase?

MRCP2-3202

A 72-year-old patient is brought to the emergency department by ambulance after experiencing sudden right-sided weakness and dysphasia for the past five hours. A CT scan confirms an ischaemic stroke with no acute bleeding, but due to the delay in seeking medical attention, thrombolysis is not an option. The patient is admitted to the stroke ward and started on aspirin, but his reduced mobility puts him at risk for haemorrhagic transformation. What is the appropriate management strategy for his risk of venous thromboembolism?

MRCP2-3203

A 12-year-old boy is brought to the Emergency Department by his worried father. The patient has been complaining of widespread back pain for the past 2 days, which has only been partially relieved with regular painkillers. He has also experienced increased clumsiness and difficulty carrying heavier objects.
Over the last 24 hours, he has had a sudden onset of weakness in both his legs to the point where he is unable to lift them off the bed. He has no known medical conditions, but he has had several upper respiratory tract infections in the past few weeks. He is not taking any medications. The only significant medical history is that he had an episode of meningitis 2 years ago, from which he made a full recovery and was discharged from the hospital 1 month later.
During the examination, he is found to have normal sensation but reduced power in both his legs. The decrease in power is symmetrical. His tendon reflexes are absent, but his abdominal reflexes are normal. Examination of his cranial nerves confirms that he has weakness of eye closure, but the optic nerves’ fundoscopic appearance is normal. No other cranial nerve abnormalities are detected. He has mild shortness of breath, no fever, and is not tachycardic. Routine tests are performed in the emergency department, including a lumbar puncture (LP). The LP results show slightly elevated protein levels and normal cell counts. His serum white cell count is 10 × 109/l.
Which of the following investigations would be most beneficial for his immediate management?

MRCP2-3204

A 35-year-old teacher presents with a 2-month history of progressive difficulty with balance and coordination. She also reports experiencing numbness and tingling on the left side of her face and in her left hand. Two years ago, she had to take time off work due to weakness and stiffness in her legs.

During the examination, Ishihara colour-plate testing revealed deficits in the right eye. Her visual acuity is 6/6 on the left and 6/36 on the right. Eye movement testing showed nystagmus of the left eye when looking towards the left, with incomplete adduction of the right eye. Additionally, there is bilateral finger nose ataxia and impaired rapid alternating movements of the hands.

What would be the most appropriate initial investigation?

MRCP2-3205

A 29 year old woman with relapsing-remitting multiple sclerosis (MS) has come to your clinic seeking advice on how pregnancy may affect her condition. She was diagnosed at age 20 and has been managed on interferon β 1a, with only four relapses in her total history. Despite mild dysdiadochokinesis of the left arm, she scores functionally very well on an expanded disability status scale (EDSS) and has no disability as a result. She is planning her first pregnancy and has already been advised to stop interferon β 1a in preparation. Apart from the impact of stopping the medication, she wants to know how pregnancy itself will affect her MS. What is the most accurate response?

MRCP2-3206

A previously healthy 68 year old patient presents to the emergency department with a sudden onset of weakness. The patient’s spouse called 911 immediately upon noticing the weakness.

Neurological examination:

CN I-IV normal
CN V ophthalmic and maxillary divisions normal with reduced sensation in mandibular division on left side
CN VI normal
CN VII reduced power to left lower facial musculature
CN VIII normal
CN IX, X and XII weakness in swallow
CN XI weakness on turning the head to the left.

Right upper limb normal tone, power 5/5, normal reflexes and sensation. Normal finger pointing.
Left upper limb markedly increased tone, power 1/5 globally in all muscle groups, brisk reflexes and reduced sensation to light touch. Unable to move limb to determine ability to finger pointing.

Right lower limb normal tone, power 5/5, normal reflexes and sensation. Heel-knee-shin test normal.
Left lower limb slightly increased tone, power 3/5 globally, brisk reflexes and reduced sensations. Reduced ability to heel-knee-shin test when compared to right side.

Gait – not assessed due to weakness.
Romberg’s test – not done due to weakness.

What is the most likely location of the lesion?

MRCP2-3207

A 75 year old man is admitted to the medical assessment unit after a fall. According to his wife, he has been experiencing frequent falls (around 2-3 times a week) for the past 4 months, resulting in multiple hospital admissions where chest infections were thought to be the main cause of his deterioration. She also reports that he has been having difficulty swallowing, frequently chokes on his food, and has been exhibiting uncharacteristic aggression. Upon examination, the patient presents with an expressionless face, kyphosed posture, and mild bilateral tremors. There is cogwheeling in both upper limbs, but his legs appear normal. His gait appears parkinsonian in character, but he is stopped after only a few steps due to unsteadiness. During cranial nerve examination, he has difficulty following downward finger movements, but the rest of the examination is unremarkable. Based on these findings, what is the most likely underlying diagnosis?

MRCP2-3208

A 42 year old woman with a history of vitiligo and pernicious anemia presents with weakness primarily affecting her shoulder and hip muscles. The weakness varies throughout the day depending on her level of activity, with symptoms being most severe at the end of the day. Her family also notes a decrease in her voice volume during these times. On clinical examination, there is evidence of proximal muscle weakness after repeated testing. Electromyography reveals a decremental response in the amplitude of successive potentials. Serum testing for antibodies to the acetylcholine receptor (AChR) is negative, and a CT scan of the thorax is normal. What diagnostic tool would be most useful in establishing a diagnosis?

MRCP2-3209

A 38-year-old woman is referred to the TIA clinic for evaluation of recurrent left arm weakness. She reports experiencing repeated episodes of left-sided weakness accompanied by a unilateral throbbing headache, nausea, and sensitivity to light. During each episode, she notices weakness in her left arm. Her medical history includes a prior diagnosis of headaches, deep vein thrombosis during pregnancy, and hypothyroidism. She does not exhibit any neurological symptoms at present. Based on this information, what is the most probable diagnosis?