A 42-year-old woman presents to the emergency department with confusion and fevers. She has no medical history and is not taking any regular medications.
Upon examination, her Glasgow coma scale is 13/15 (E3V4M5) and there are no localizing neurological signs. Cardiovascular, respiratory, and abdominal assessments are unremarkable. Her temperature is 38.8ºC.
An urgent MRI brain is scheduled, which reveals oedema of both temporal lobes.
A lumbar puncture is ordered.
What is the most likely set of results that will be found?
MRCP2-3197
A 16-year-old male is admitted to the hospital with worsening weakness in his limbs over the past 48 hours. He is experiencing difficulty walking and has become increasingly clumsy, dropping objects frequently. He also suffered a burn on his hand yesterday without realizing it until later. He reports feeling dizzy upon standing, but denies any chest pain or palpitations. He had a recent bout of vomiting and diarrhea four weeks ago, but is otherwise healthy and does not take any medications or use alcohol or tobacco.
During the examination, the patient’s blood pressure drops from 128/79 mmHg while lying down to 90/60 mmHg upon standing. His respiratory rate is 20 breaths per minute and his oxygen saturation is 97% on room air. His cardiovascular, respiratory, and abdominal exams are unremarkable. Neurological examination reveals symmetrical distal weakness in his lower limbs with relative proximal sparing and altered sensation to fine touch, vibration, and proprioception. Similar findings are observed in his upper limbs. The patient is suspected to have Guillain-Barre syndrome and is started on IV immunoglobulins after undergoing blood tests, CT head, and lumbar puncture. However, he begins to experience increasing shortness of breath and is referred to the intensive care unit for respiratory support.
What is the respiratory parameter used to determine the need for invasive ventilator support in this patient?
MRCP2-3198
A 65-year-old man with a history of type 2 diabetes and hypertension presents to the Emergency Department with weakness on the right side of his face and arm, which started five hours ago. Upon assessment, it is evident that he has had an acute stroke. What is the systolic blood pressure threshold that would require immediate treatment in this case?
MRCP2-3199
A 57-year-old male presents to the Emergency Department with a sudden onset of weakness in his right arm and leg that started while he was at work. He reports some improvement in strength but still feels definite weakness. His medical history includes hypertension, hypercholesterolaemia, and a previous myocardial infarction. He is currently taking lisinopril 10mg OD, atorvastatin 40 mg OD, and aspirin 81mg OD. On examination, he has a right-sided hemiplegic gait and decreased power (3/5) in all muscles of the right upper and lower limbs, with decreased tone and absent deep reflexes. Sensation and coordination testing are unremarkable. His blood pressure is 160/90 mmHg, heart rate 80 bpm, respiratory rate 18/min, temperature 37.0 C, and oxygen saturations 98% on air. His ECG shows sinus rhythm with left ventricular hypertrophy. CT head scan shows no evidence of intracranial haemorrhage, mass shift, or space-occupying lesions. What is the next best management step?
MRCP2-3200
A 59-year-old man presents to the neurology clinic with a history of increasing bilateral hand weakness and clumsiness over several months, with the right hand being worse than the left. He reports difficulty with writing, fine manipulation, and poor hand grip. He denies any sensory disturbance or neck problems but has recently developed weakness in his right knee. His medical history includes hypertension and hypercholesterolemia, and he takes bendroflumethiazide and simvastatin regularly. He smokes 20 cigarettes per day and drinks 10 units of alcohol per week. On examination, there is bilateral hand and forearm wasting with absent clawing or fasciculations, and reduced muscle bulk of the proximal musculature. Shoulder abduction/adduction is 3/5, and there is marked distal weakness affecting wrist and finger flexors of 2/5. Sensation is intact. Investigations reveal a fasting plasma glucose of 8.5 mmol/L, and a lumbar puncture shows an opening pressure of 10 cmH2O, CSF protein of 0.35 g/L, and CSF white cell count of 4 cells per ml. Which investigation is most likely to confirm the diagnosis?
MRCP2-3191
A 32-year-old woman presents to the emergency department with abdominal pain. She has a history of mild depression and hay fever, and takes paroxetine and PRN loratadine. She reports experiencing generalised colicky abdominal pain and has vomited once in the department. On examination, her blood pressure is 155/86 mmHg, heart rate is 95 bpm, and temperature is 37.9ºC. A digital rectal examination reveals hard stool in the rectum. Investigations reveal Hb 131 g/l, platelets 362 * 109/l, WBC 7.3 * 109/l, Na+ 121 mmol/l, K+ 3.3 mmol/l, urea 6.2 mmol/l, creatinine 87 µmol/l, and a urine dipstick showing protein ++ and leucocytes ++. What is the most likely diagnosis?
MRCP2-3192
A 75-year-old man arrives at the emergency department by ambulance after experiencing sudden speech difficulty, numbness, and weakness for the past eight hours. Despite his symptoms, he was hesitant to seek medical attention due to concerns about the ongoing coronavirus pandemic. The patient has a medical history of hypertension, hypercholesterolemia, and ischemic heart disease, and is currently taking aspirin, atorvastatin, bisoprolol, and amlodipine. He is a non-smoker and drinks only minimal amounts of alcohol. He typically lives independently with his wife.
Upon examination, the patient exhibits expressive dysphasia and right-sided hemisensory loss affecting his face, arm, and leg. There is also evidence of facial weakness, and his right upper limb has a power of 3/5 while his right lower limb has a power of 4/5. Chest auscultation is normal, heart sounds are audible with no murmurs, and his pulse is irregular. There are no carotid bruits. Urinalysis is unremarkable, and bedside testing reveals a glucose level of 7.1 mmol/L. An ECG shows atrial fibrillation, and an urgent CT angiography reveals occlusion of the proximal anterior circulation. An hour later, a diffusion-weighted MRI shows limited core infarct volume.
What is the most appropriate course of action for this patient?
MRCP2-3186
A 44-year-old white Caucasian female presents to the Emergency Department with complaints of being unable to walk and problems with vision in her right eye. She has no significant medical history and has only visited her GP once before for a bout of diarrhoea and vomiting.
On examination, a right relative afferent pupillary defect is noted, and there is a patchy loss of sensation on the right lateral wrist and anterior aspect of the left lateral shin. An urgent MRI head and whole spine reveals abnormal high signal in the cervical cord from C3 to C7. A lumbar puncture was performed, and the results show a WCC of 12 mm/³, RBC <1 mm/³, protein of 0.9 g/l, glucose of 5.2 mmol/l (10.2 mmol/l serum), and oligoclonal bands and viral PCR results are pending.
What is the most likely diagnosis?
MRCP2-3187
A 65-year-old woman presented with symptoms of dizziness, nausea, and vomiting that had developed gradually over the past day. She reported a constant sensation of the room spinning, which worsened with sudden movements. The patient had experienced flu-like symptoms the previous week, which were now resolving. During the examination, the patient exhibited horizontal nystagmus with the fast beat towards the right. Speech was normal, and finger-nose testing and gait were normal. There was no past-pointing, and the patient had 5/5 power throughout all limbs. Hearing was normal. What is the most likely diagnosis?
MRCP2-3189
A 50-year-old man presents with complaints of lower limb numbness and weakness, along with recent urinary incontinence and blurred vision. On examination, he has bilateral lower limb weakness (grade 3+/5) with spastic tone and exaggerated reflexes. Sensory level is at T10. MRI of the spine shows a hyper intense lesion spanning from T7-T12. His medical history includes well-controlled asthma with salbutamol inhaler. Laboratory investigations reveal normal electrolytes, renal function, and urine analysis, with negative ANA. CRP and ESR are mildly elevated. Which investigation would be most helpful in reaching a diagnosis?