Archives: MRCP Part 2

MRCP2-3107

A 55-year-old construction worker visited his doctor complaining of weakness in his right shoulder and arm. He had difficulty lifting heavy objects above his head and had recently experienced reduced hand grip and numbness. These symptoms had gradually developed over the past two months after he fell from a plinth while working. The patient had a history of hypertension and mild asthma, smoked 20 cigarettes per day, and consumed 20 units of alcohol per week.

During the examination, the doctor observed winging of the right scapula and some wasting of the dorsal interossei and thenar eminence of the right hand. The patient had reduced tone in the right biceps and wrist, with absent biceps, triceps, and supinator jerks. Power testing revealed weakness in the right peri-scapular muscles, shoulder abduction, elbow flexion and extension, finger flexion and extension, and opposition of the thumb. Sensation was diminished over the thumb, right middle, ring, and little finger, extending over the medial and lateral aspect of the right forearm.

EMG and nerve conduction studies showed fibrillation potentials affecting small muscles of the right hand, with absent sensory nerve action potentials. Studies in the left arm were normal. Based on these findings, what is the most likely diagnosis?

MRCP2-3108

A 42-year-old homeless man is brought to the Emergency Department by the police. He claimed he was ill, with a headache, vomiting and neck and arm stiffness after being asked to move on from a shop doorway. On examination, he is pyrexial (37.8 °C) and has signs of mild meningism. Ophthalmoscopy reveals a small, grey–white choroidal nodule on the right-hand side and bilateral lateral rectus palsies are observed. Following neuroimaging, lumbar puncture is performed. Investigations reveal abnormal results for haemoglobin, white cell count, sodium, and protein. Magnetic resonance imaging (MRI) brain shows a small nodular enhancing lesion and chest X-ray (CXR) shows left upper lobe fibrosis/consolidation. Cerebral spinal fluid (CSF) analysis reveals elevated protein levels, lymphocytic cell count, and low glucose levels. Based on these findings, what is the most likely diagnosis?

MRCP2-3109

A 65-year old man presents to the clinic with a 2-week history of tingling in his hands and feet. He has also noticed that his legs feel weaker than usual. He has a history of high blood pressure and no other medical conditions. His vital signs are stable, but he appears sweaty and has a rapid heart rate. On examination, he has bilateral facial weakness and grade 4 weakness in his upper and lower limbs. His reflexes are present but require reinforcement. He has reduced sensation in his toes, ankles, and fingers. Which investigation is most likely to aid in the suspected diagnosis?

MRCP2-3110

A 65-year-old man presents with a 12-month history of forgetfulness and paroxysmal drowsiness. Upon examination by his GP, bilateral bradykinesia and rigidity in the upper limbs were found, and he was started on L-dopa. However, six weeks later, he developed formed visual hallucinations that persisted despite stopping the medication. The GP then prescribed a small dose of haloperidol (5 mg), but the patient experienced severe vomiting and drowsiness, which resolved upon discontinuing the medication. The patient has mild bradykinesias and rigidity in the upper limbs with rest tremor of the left arm, and his mini mental examination score is 20/30. The remainder of the examination is normal.

Investigations show normal results for CT brain and EEG, as well as for haemoglobin, white cell count, platelets, serum sodium, serum potassium, serum urea, serum creatinine, serum albumin, serum total bilirubin, serum aspartate aminotransferase, serum alkaline phosphatase, plasma glucose, free T4, free T3, and plasma TSH. However, the serum vitamin B12 level is low at 228 ng/L (160-760), and VDRL is negative.

What is the most likely diagnosis?

MRCP2-3111

A 44-year-old woman with a relapsing and remitting multiple sclerosis history presents for follow-up at the clinic. She has been stable for the last 6 months and is currently on oral fingolimod treatment. During the neurological examination, there is noticeable coordination impairment, particularly on the left side, but no other significant indications.
What accurately describes the mechanism of action of fingolimod?

MRCP2-3112

A 19-year-old man presents with painless visual loss in his left eye over the course of 24 hours. He had previously lost vision in his right eye over the past two weeks, with no improvement in the following two months. He denies any other symptoms and has no significant medical history. He smokes 10 cigarettes per day and drinks 20 units of alcohol per week. Physical examination reveals bilateral optic atrophy and impaired color vision in both eyes. All other neurological exams are normal. Various tests, including a full blood count, liver function tests, and MRI brain and orbits, all come back normal. What is the most likely diagnosis?

MRCP2-3113

A 28-year-old female presents to the Emergency department with complaints of headaches and diplopia. She reports experiencing a generalised and throbbing headache with associated nausea since the morning. Over the last two hours, she has noticed pain and double vision when looking to the right, and her left eyelid has started to droop. She denies any changes in facial sensation or weakness in her arms or legs. Her medical history includes migraines, for which she occasionally takes Imigran. She is a smoker and drinks alcohol regularly.
On examination, she is alert and oriented with mild nuchal rigidity. Fundoscopy is normal, but she has photophobia. Cranial nerve examination reveals a left oculomotor nerve palsy with left-sided ptosis and mydriasis. There is no evidence of chemosis or proptosis, and the rest of the cranial nerves and visual fields appear normal. Peripheral nervous system examination is unremarkable.
Laboratory investigations show a slightly low serum potassium level and a mildly elevated C-reactive protein level. Given the clinical presentation, which investigation is most likely to lead to a definitive diagnosis?

MRCP2-3114

A 60-year-old woman presents to a neurologist with worsening morning headaches that are throbbing and accompanied by nausea. She reports that the headaches are positional and worsen when lying down. Additionally, she has noticed a decline in her sense of smell and has difficulty seeing out of her right eye. She denies pain or diplopia but has been experiencing left-sided clumsiness. She has a medical history significant for hypertension, hypercholesterolemia, and ischemic heart disease and takes aspirin, ramipril, and simvastatin. She smokes 10 cigarettes per day and drinks four units of alcohol per week. On examination, she has bilateral non-tender pulsatile temporal arteries and a sluggish direct pupillary reflex on the right with a relative afferent pupillary defect. Fundoscopy reveals right optic atrophy and mild swelling of the left optic disc with peripapillary hemorrhages. Visual field testing shows a central scotoma on the right and restriction of visual fields on the left. The rest of the cranial nerves are normal, and examination of the peripheral nervous system is unremarkable. Laboratory investigations are within normal limits except for a slightly elevated white cell count and a low ESR. What is the most likely diagnosis for this patient’s symptoms?

MRCP2-3115

A 58-year-old man presented to his GP with complaints of weight loss and weakness that he had been experiencing for some time. He mentioned that his clothes no longer fit him properly. He had noticed progressive weakness in both his legs, along with wasting of the thighs and thinning around the ankles. Additionally, he had been experiencing slurring of speech and nasal regurgitation while eating. His medical history included chronic bronchitis, prostatic hypertrophy, and osteoarthritis affecting the cervical and lumbar spine. He was currently taking a salbutamol and beclasone inhaler.

Upon examination, the patient appears cachectic with muscle wasting in his arms and legs. Chest and abdominal examination appeared normal. Cranial nerve examination revealed a pseudobulbar palsy, decreased palatal elevation, and wasting of the tongue with fasciculations. There was also a brisk jaw jerk. Upper limb examination showed normal tone, but asymmetrical wasting of the forearms and dorsal interossei bilaterally. There was also asymmetrical weakness of hand grip (right greater than left) and weakness of wrist flexion/extension. Reflexes appeared pathologically brisk, and there were positive Hoffman signs bilaterally. Lower limb examination revealed bilaterally increased tone with fasciculations of the thighs. There was marked weakness of dorsiflexion and plantar flexion of the left foot and bilateral weakness of hip flexion that was more pronounced on the left than the right. Sensory examination and cerebellar function were normal.

Blood tests showed normal liver function, sodium, potassium, urea, creatinine, and prostate specific antigen levels. The patient’s calcium level was slightly elevated. MR brain and chest x-ray were normal, but MRI spine showed degenerative disc disease affecting the lumbar and cervical spine. Electromyography and nerve conduction studies revealed spontaneous fasciculation potentials affecting all four limbs.

What is the most likely cause of this patient’s symptoms based on his history and clinical findings?

MRCP2-3101

An 80-year-old man comes to the clinic with a festinant gait. His wife reports that he has been drooling saliva and his voice has become quieter over the past six months. During the examination, it is observed that he has a resting tremor in his right hand and increased rigidity in his right upper limb. What factor would make idiopathic Parkinson’s disease less likely in this case?