Archives: MRCP Part 2

MRCP2-3094

A 25-year-old female presents with a persistent headache for the past eight weeks, which has worsened in the last week. She reports a constant frontal headache that is not relieved by paracetamol. The headache is present when she wakes up in the morning and persists throughout the day. Additionally, she has gained over 7 kg in weight in the last six months. On examination, she appears tearful and has a BMI of 32 kg/m2. However, there is no nuchal rigidity, and neurological examination is normal except for bilateral optic disc swelling on fundus examination. Her blood pressure is 122/88 mmHg, and her temperature is 37°C. What is the most appropriate investigation to make a diagnosis?

MRCP2-3095

A 55-year-old woman presents with a four-month history of slurred speech, unsteadiness of gait, and progressively worsening symptoms. She also experiences a tremor in her right hand and diplopia on right lateral gaze. She has a history of breast carcinoma and mild rheumatoid arthritis, for which she takes diclofenac. She smokes 30 cigarettes a day and drinks fewer than 10 units of alcohol per week. On examination, she has dysarthria, a right intention tremor, dysdiadochokinesis with past pointing, and a broad-based gait with a lean to the right. There is also evidence of a right VIth nerve palsy and mild facial weakness on the right side. Further investigations reveal abnormal CSF analysis with oligoclonal bands present and an MRI scan shows a calcified lesion attached to the petrous part of the temporal bone. What is the likely cause of this patient’s symptoms?

MRCP2-3096

A 50-year-old woman presented with a 6-month history of difficulty in swallowing. She had been well until 20 months ago when she noticed she could not hear as well in her left ear. Shortly after this, she noticed she could hear her heart beating loudly in her left ear. These problems had continued over the last year and a half but in the last 6 months she had also noticed problems in swallowing, particularly liquids. Her husband had commented that over the same time period her voice was much hoarser than it had been previously.

On examination she had a hoarse voice, wasting of the sternocleidomastoid and trapezius on the left and a decreased gag reflex. Rinne’s test showed AC > BC on the right and BC > AC on left (AC = air conduction, BC = bone conduction); Weber’s test lateralised to the left ear. The remainder of the neurological examination was normal.

What is the most likely diagnosis?

MRCP2-3097

A 25-year-old woman presents to her GP with progressive unsteadiness, numbness, and weakness in her lower legs, as well as slurred speech. She reports a history of being clumsy as a child and follows a vegan diet. On examination, she has dysarthria, bilateral optic atrophy, and horizontal nystagmus. Her upper limb reflexes are depressed, and there is reduced vibration sense. In her lower limbs, she has bilateral pes cavus, distal muscle wasting, absent ankle and knee jerks, and a pyramidal distribution of weakness. Sensory examination reveals reduced vibration and joint position sense. Her gait is ataxic, and Romberg’s test is positive. Blood tests show elevated glucose levels, and a double apical impulse and ejection systolic murmur are noted on cardiovascular examination. CSF analysis reveals elevated protein levels but no oligoclonal bands. What is the likely diagnosis?

MRCP2-3098

A 50-year-old man presents with a six-month history of proximal weakness in both upper and lower limbs, dry mouth, and impotence. He is a heavy smoker, consuming 30 cigarettes per day, and drinks 12 units of alcohol per week. Apart from this, he has been healthy. On examination, he is an obese individual with a blood pressure of 155/90 mmHg and is apyrexial. Chest, heart, and abdominal examination are normal. There is proximal weakness grade 4/5 in both upper and lower limbs. The reflexes are generally depressed, plantars are flexor, and sensation is normal. What is the most likely diagnosis?

MRCP2-3099

A 40-year-old female presents with a history of feeling fatigued after mild exertion for the past six months. She has also been experiencing difficulty with attention. Despite being diagnosed with fibromyalgia and attempting graded exercise, she has not noticed any improvement and seeks further opinion.

On examination, the patient appears to be in reasonable health with a BMI of 29 and a blood pressure of 128/84 mmHg. She exhibits partial ptosis on the right side of her face, along with nasal speech that worsens with sustained activity. Her pupillary size and reaction are normal, and her deep tendon reflexes are normal throughout. The patient’s anti-acetylcholine receptor antibody test was negative.

What investigation would be appropriate to confirm the clinical impression?

MRCP2-3100

A 28-year-old woman presents to her GP with her boyfriend. She reports that over the past few months, her boyfriend has been hearing voices that demand him to do things or simply hum or laugh. He also believes that she is plotting to leave him for his brother and that he has a deadly illness with less than a year to live. These delusions have caused significant strain on their relationship, and he has lost weight, become increasingly nervous, and neglected his appearance. He has no known medical problems, is a smoker of 20 cigarettes per day, and drinks 15 units of alcohol per week. On examination, he appears withdrawn and unkempt, fidgeting with his clothes and commenting on a fishy smell. His mini-mental state examination score is 30/30, and there are no abnormalities on cranial nerve or peripheral nervous system examination or on an MRI scan of his brain. What is the most likely diagnosis for this patient?

MRCP2-3089

A 40-year-old man visits his primary care physician with a history of occasional difficulty speaking and reduced facial expressions. He also reports occasional regurgitation of food through his nose, which he finds embarrassing. His symptoms are most severe at the end of the day. He has no significant medical history and takes no regular medications.
During the examination, his vital signs are normal. His heart and lungs are functioning normally, and he has no motor or sensory deficits. He reports blurred vision during visual field testing.
What is the initial investigation to request, given the probable underlying diagnosis?

MRCP2-3090

A 55-year-old woman presents to the Emergency department with progressive weakness and numbness in both legs. Her symptoms have developed over the course of a week, and she has also noticed numbness and weakness in her hands, double vision, and weakness in her facial muscles. She has a history of rheumatoid arthritis and was recently diagnosed with diabetes due to long-term steroid use. On examination, she has cushingoid features, restricted left lateral gaze, bilateral facial weakness and dysarthria, reduced tone in the upper limbs, marked weakness of handgrip and wrist flexion/extension bilaterally, absent reflexes, and sensory loss to all modalities extending up to the elbow bilaterally. In the lower limbs, she has flaccid tone bilaterally, some wasting and weakness of the proximal muscles, marked weakness of dorsiflexion and plantarflexion of the foot bilaterally, absent reflexes, and reduced sensation to all sensory modalities extending to the knee bilaterally. Blood tests show normal sodium and urea levels, low potassium levels, elevated creatinine levels, and high HbA1c levels. The erythrocyte sedimentation rate is also elevated, and the lumbar puncture shows elevated CSF protein levels and low CSF glucose levels. How would you initially manage this patient?

MRCP2-3091

A 65-year-old man presents to the neurology clinic with complaints of excessive daytime drowsiness despite good sleep patterns. His wife reports that he appears vague and drowsy at times during the day, with fluctuating attention span. He has also been experiencing visual hallucinations and has become increasingly slow at dressing and walking. His medical history includes hypertension treated with bendroflumethiazide and a previous left-sided cerebrovascular accident with good recovery. He is a smoker and drinks 10 units of alcohol per week. On examination, he has a small goitre and hypophonia with an expressionless face. His mini mental state examination reveals deficiencies in verbal fluency, executive function, and visuospatial testing. Peripheral nervous system examination reveals bradykinesia, increased tone bilaterally, and unilaterally brisk reflexes on the left with delayed relaxation on the right. The left plantar response is extensor. Thyroxine levels are low, and thyroid stimulating hormone levels are high. What is the best next step in managing this patient?