A 33-year-old female patient presents with a four-week history of bifrontal headache, decreasing visual acuity, and walking difficulties. She has no significant medical history. On examination of cranial nerves, there is bilateral VIth nerve palsy, and fundoscopy reveals bilateral papilloedema. Visual acuity is reduced, and gait is ataxic. Routine blood count reveals an elevated platelet count of 867 ×109/L. Haemoglobin, haematocrit, white cell count, iron store, and inflammatory markers are all normal. MRI brain shows cerebral venous sinus thrombosis with a small cerebellar haemorrhage. What is the best next step in managing this patient?
MRCP2-3146
A 32-year-old caucasian woman is 28 weeks pregnant. She has been epileptic since the age of 7 and takes lamotrigine, which she has continued throughout the pregnancy. She has not had a seizure for 2 years. What factors should be taken into account for pregnant patients on lamotrigine?
MRCP2-3149
A 32-year-old woman who recently traveled to Brazil presents to the Emergency Department with fever, headache, and muscle pain. She has a history of insulin-dependent diabetes mellitus. She is admitted due to worsening headache and back pain and becomes increasingly drowsy while waiting in the medical receiving unit. On examination, she has flaccid paralysis and decreased tendon reflexes. A CT scan of the brain is normal. Cerebrospinal fluid examination shows a protein level of 1.2 g/l (normal < 0.45 g/l), glucose level of 3.8 mmol/l (normal 2.5-3.9 mmol/l), and a white cell count of 200/mm3 (mostly lymphocytes) (normal < 5/mm3). Laboratory investigations reveal a hemoglobin level of 140 g/l (normal 135-175 g/l), platelet count of 400 x 109/l (normal 150-400 x 109/l), white cell count of 11.0 x 109/l (normal 4.0-11.0 x 109/l), sodium level of 138 mmol/l (normal 135-145 mmol/l), potassium level of 4.5 mmol/l (normal 3.5-5.0 mmol/l), creatinine level of 110 µmol/l (normal 50-120 µmol/l), and a urea level of 6.5 mmol/l (normal 2.5-6.5 mmol/l). What is the most likely infectious process?
MRCP2-3150
A 35-year-old construction worker presented to the Emergency department with symptoms of vertigo, dysarthria, ataxia, nausea, and vomiting. He reported experiencing severe occipital pain for the past five hours, which began while he was working on a construction site. He denied any hearing or visual impairments and had no past medical history or prescribed medication use. He was a smoker of 20 cigarettes per day and drank 20 units of alcohol per week, but denied any illicit drug abuse. There was a family history of stroke, and his mother had died of subarachnoid hemorrhage at the age of 43.
Upon examination, the patient was pale and vomiting and complained of severe occipital head pain. His pulse was 80/min and regular, blood pressure was 120/80 mmHg, and temperature was 36.5°C. Heart sounds were normal, and fundoscopy showed no abnormalities. However, his pupils appeared sluggishly reactive to light. During cranial nerve examination, he exhibited gaze-evoked nystagmus towards the right and had a marked dysarthria. On peripheral nervous system examination, there was an intention tremor of the right arm. Tone, power, reflexes, and sensation were all normal. On lower limb examination, he walked with an ataxic gait and appeared to be veering towards the right.
Based on these findings, what is the likely diagnosis for this 35-year-old construction worker?
MRCP2-3151
A 19-year-old female presents to the clinic with complaints of speech difficulties and slowing of movements. Upon examination, bilateral rigidity, akinesia with loss of arm swing, and bradykinesia are observed. Which medication could be responsible for inducing this disorder?
MRCP2-3152
A 31-year-old man presents with left eyelid drooping and drooling from the side of his mouth. This started three weeks ago and he has also been experiencing fatigue. He denies having a fever and reports no weakness in any other parts of his body. He has a dry cough that he attributes to hay fever. His left ear has reduced hearing and has been painful.
Additionally, he has a faded red rash on his legs. He has no past medical history, has not traveled abroad, and is sexually active with a single male partner. He had shingles three months ago.
During the examination, he has a clear left-sided facial droop with normal sensation and no sparing of the forehead. He has normal power in all four limbs with no sensory loss. There is a faint red circle on the right leg surrounding a central red area within. Scattered crepitations are present in the lungs. He has pain in his left ear with an effusion behind the tympanic membrane.
ECG sinus, PR interval 202ms Chest x-ray no abnormalities seen
What is the likely diagnosis?
MRCP2-3155
A 25-year-old man attends the Epilepsy Clinic. He has suffered tonic-clonic seizures for 7 years. After initial poor response, his epilepsy is now well-controlled on sodium valproate 1.5 g daily. He has been seizure-free for 3 years. His compliance with therapy is good.
From review of his case sheet, you note a family history of cerebrovascular disease with both grandparents suffering stroke.
At time of diagnosis, magnetic resonance imaging (MRI) brain showed no structural abnormality and interictal electroencephalogram (EEG) was unremarkable.
He is concerned over weight gain and hair loss that he attributes to his anticonvulsant therapy. He is considering stopping his sodium valproate.
What feature in his history predicts seizure recurrence upon discontinuation of therapy?
MRCP2-3156
A 40-year-old man presents to the Emergency department after being assaulted in the city centre. He sustained multiple knife wounds, including two in the left groin. On examination, there is reduced power of hip flexion and knee extension on the left, along with reduced sensation over the medial aspect of the left thigh. What is the probable cause of his symptoms?
Investigations revealed normal full blood count and biochemistry, with a glucose level of 5.6 mmol/L (3.0-6.0) and a prothrombin time of 11.5 s (11.5-15.5). A plain x-ray of the pelvis showed no evidence of fracture. The patient is a previously fit individual who smokes 10 cigarettes per day and drinks approximately 20 units of alcohol per week.
MRCP2-3157
A 44-year-old woman presents to the emergency department with symptoms of dysphasia, visual disturbance, and weakness that have been ongoing for two hours. Upon examination, she is found to have left homonymous hemianopia, left-sided hemiparesis with sensory loss, and dysphasia. Her vital signs are stable, with a heart rate of 102/min and blood pressure of 145/82 mmHg.
An urgent CT head and angiography are scheduled, which reveal a large infarct in the territory of the middle cerebral artery in the right cerebrum, with proximal occlusion seen on the CT angiography.
The patient has no significant medical history, and her blood work is normal. Her modified Rankin score is 1, and her national institutes of health stroke scale (NIHSS) is 12.
Given that four hours have passed since presentation, what is the next most appropriate course of action in her management?
MRCP2-3158
A 25-year-old man visits the neurology clinic after experiencing his second seizure. According to his partner, the patient becomes unresponsive and appears to be ‘staring into space’ during these episodes. The patient has no memory of these events but does recall feeling nauseous and disorientated for several hours afterward.
All blood tests to identify electrolyte abnormalities come back normal, and an MRI of the head shows no abnormalities. However, an EEG reveals interictal epileptiform discharges.
What would be the most appropriate first-line drug therapy for this likely diagnosis?