Archives: MRCP Part 2

MRCP2-3092

A 45-year-old woman presented to her GP with complaints of visual impairment. She had been experiencing difficulty navigating around furniture for some time. She also reported worsening headaches over the past two weeks and had recently experienced two complex partial seizures. Her medical history included partial epilepsy diagnosed at 20 years of age and treatment with vigabatrin. She was currently taking lamotrigine and smoked 10 cigarettes per day and drank 8 units of alcohol per week. On examination, she had a marked bitemporal inferior quadrantanopia and some paraesthesia affecting the left ophthalmic branch. Investigations revealed elevated prolactin levels. What is the likely diagnosis?

MRCP2-3093

A 25-year-old female patient presents with a medical history of recurring episodes of dysarthria, ataxia, and diplopia lasting for 20-30 minutes, followed by a severe headache on the right side accompanied by vomiting that lasts for one to three days. These episodes occur once every month. The patient’s MRI brain and MR angiogram results are normal. What is the probable diagnosis?

MRCP2-3066

A 28-year-old woman presented with a 4-month history of feeling down and a sensation of being followed by people wherever she goes. She has no previous medical history and is not taking any prescription medication, but she admits to occasionally using marijuana since her teenage years and more frequently in the past 4 months. The onset of her symptoms coincided with the death of her mother from cancer 8 months ago.

During the neurological examination, she exhibited occasional facial grimacing and twisting movements of her limbs. Her tone, strength, and reflexes were all within normal limits. Cranial nerve assessment was unremarkable, except for slow saccadic eye movements and difficulty maintaining tongue protrusion.

What is the most effective method to confirm the probable diagnosis?

MRCP2-3069

A 52-year-old man presents to the acute medical intake with a two-week history of severe pain around his right eye. The pain began without any apparent cause and woke him from his sleep. He describes the pain as severe and boring, radiating upwards over the right frontal and temporal region. The pain is not constant but seems to start every evening and persist for periods of 20 minutes to over an hour. The headaches are associated with watering of his right eye and a blocked left nostril. He has no past history of similar episodes or any other significant medical history.

Upon examination, he is alert and oriented with a Glasgow coma scale score of 15/15. His blood pressure is 125/75 mmHg, and he is afebrile with no neck stiffness. The right eye is red with conjunctival injection and mild eyelid edema. There is a partial right-sided ptosis and miosis.

Which therapeutic option is most likely to alleviate his symptoms?

MRCP2-3070

A 31-year-old male presents with his 4th episode of worst ever headache in one week. He describes the headache to always be of sudden onset on the left side of his head, of 10 out of 10 severity and that he finds bright lights extremely distressing during these periods. The episodes last for around 30 minutes, typically after dinner. He also describes redness and swelling of his left eye and a blocked left nostril during the headaches, associated with tearing of his left eye.

He has no past medical history and family history of migraines. He denies illicit drug use, is a non-smoker and drinks two glasses of wine with dinner every night. Over the past 7 days, he has been self-medicating with paracetamol and ibuprofen. On examination, you notice no focal neurology, no meningism and fundoscopy is unremarkable.

What is the most likely diagnosis?

MRCP2-3071

You are working in a neurology outpatient clinic seeing a patient referred from a local GP clinic. She’s a 38-year-old woman who has been troubled by severe headaches over the past half a year. These headaches are the worse that she’s ever had in her life, describing them as far worse that the compound fracture she sustained four years ago. These headaches tend to happen most nights at around 2am just after she falls asleep. She often paces around her kitchen for a couple of hours and often resorts to bashing her head against the fridge the pain is so bad. When probed further she mentioned that she gets a sense of fullness in her right ear (which is the side that the headache most often occurs on). She remembers having a similar problem a couple of years ago that lasted a few months before resolving on their own.

What medication is most likely to prevent these headaches?

MRCP2-3072

You have been referred a 40-year-old man by the Accident and Emergency doctors with a severe headache. The headache woke him up at 3am, and he describes it as the worst headache he’s ever had, (although he admits he’s not a regular headache sufferer). He has had seven episodes like this over the past two weeks that have followed a very similar pattern, with the other two headaches lasting around 60 minutes before going.

The pain is mainly around the left eye and temple and is sharp in nature. You have to ask him to sit down to examine him because he is up and pacing around his room, clearly very agitated. On examining him you note that his left eye is watering and swollen, and there’s some redness and mild bruising just above the eye. When you ask him about this bruising he says that the pain was so bad he bashed his head against the fridge door to try and help take it away.

On examination he has normal power, sensation and reflexes in all four limbs. On examining his cranial nerves you notice that he has a mild left sided ptosis and miosis, and there is conjunctival injection and lacrimation on that side too.

What is the most likely cause of his headache?

MRCP2-3075

A 32-year-old woman has been feeling unwell for the past 8 months. Her partner accompanies her to the Psychiatry Clinic to provide additional information about her condition. The symptoms are recurrent, with repetitive behavior during each episode. She experiences sudden confusion and begins to chew her nails. She moves around and resists any attempts to restrain her physically. After a few minutes, she recovers but has no memory of the preceding moments. She reports having had febrile convulsions as a child, but there is no family history of epilepsy. The psychiatric examination is normal.

What is the most likely diagnosis?

MRCP2-3076

A 42-year-old Asian man presented to the hospital after experiencing three generalised seizures. He had been complaining of headaches, increased thirst and urination, and sudden weakness in his right arm and leg. Over the past week, he had become increasingly confused and lethargic. The patient had a history of hypertension and was taking bendroflumethiazide. He also smoked 30 cigarettes per day and had recently seen his GP for arthritic pain in his back and knees.

Upon examination, the patient appeared dehydrated with decreased skin turgor and dry mucous membranes. He had a left lower motor neurone facial nerve palsy and red, inflamed eyes. Peripheral nervous system examination revealed a right-sided hemiparesis with brisk reflexes and a mute left plantar response.

Investigations revealed a left anterior circulation infarct on a CT scan of the brain, as well as bilateral hilar lymphadenopathy and fibrotic interstitium on a chest x-ray. The patient’s CSF analysis showed elevated protein and lymphocytes, as well as positive oligoclonal bands.

What is the likely diagnosis for this 42-year-old Asian man?

MRCP2-3077

You are requested to evaluate a 15-year-old Caucasian girl who has been feeling unwell for a few days. She has been experiencing intermittent fevers and chills and complains of extreme fatigue. Suddenly, half an hour before her admission to the hospital, she lost all vision in her left eye.

During the examination, the patient appears pale and unwell. Her vital signs are as follows: temperature 38.5°C, pulse 120/minute, regular, blood pressure 100/55 mmHg, and respiratory rate 22/minute. A pansystolic murmur is audible at the apex and lower left sternal border. Both lungs are clear.

The right pupil reacts normally to light, but there is no reaction from the left pupil, which remains fixed and dilated. The patient has complete loss of vision in the left eye, and the left fundus appears paler than the right, with no papilloedema. The only additional finding on examination was a paronychia on her right thumb, and light pressure on the nail bed was very uncomfortable.

Investigations reveal the following results: Hb 109 g/L (115-165), WBC 14.1 ×109/L (4-11), Neutrophils 9.0 ×109/L (1.5-7), Lymphocytes 4.8 ×109/L (1.5-4), Monocytes 0.29 ×109/L (0-0.8), Eosinophils 0.01 ×109/L (0.04-0.4), and Platelets 550 ×109/L (150-400).

What is the most crucial investigation to determine the cause of her illness?