Archives: MRCP Part 2

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?

MRCP2-3073

A 45-year-old man presents to his GP with recurrent severe headaches. The headaches occur episodically every three to six months, with daily headaches lasting up to eight weeks at a time. The patient reports being woken up at 2 am with severe right peri-ocular pain, which typically lasts for 30-60 minutes. During these attacks, he also experiences right-sided nasal congestion and lacrimation. The patient denies nausea, vomiting, photophobia, or phonophobia. He is a business executive, a smoker of 20 cigarettes per day, and drinks 30 units of alcohol per week. On examination, there is mild right-sided ptosis, red and watery right eye, and pupillary constriction. The rest of the cranial nerves appear intact, and fundoscopy is normal. There are no abnormalities detected on the peripheral nervous system examination. The MRI brain and MR angiography are normal. What is the most likely treatment to alleviate this patient’s acute symptoms?

MRCP2-3074

You are requested to assess a 26-year old female who has just given birth on the labour ward. Her baby boy was born with severe hypotonia and needed resuscitation and ventilation. Upon examination, she displays bilateral ptosis, global weakness (with more pronounced distal weakness), and bilateral cataracts. She mentions that her father had bilateral cataracts and passed away at the age of 59. What is the probable diagnosis for the mother?

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?

MRCP2-3078

A 32-year-old woman with a history of epilepsy presents to the Outpatient Clinic seeking advice on starting the oral contraceptive pill. She has been taking carbamazepine as her sole anti-epileptic medication for the past four years and has been seizure-free for the last 18 months on her current dose. What is the optimal approach to managing her situation?

MRCP2-3060

A 28-year-old male patient complains of nasal congestion for the past six months. An ENT specialist previously diagnosed him with sinusitis. However, he returns with a new symptom of right periorbital swelling and double vision that started two days ago. Upon examination, the patient appears unwell with a temperature of 37.4°C. Although he does not have neck stiffness or photophobia, his right eyelid droops significantly, and his right eye is congested and deviated to the right with an enlarged pupil. The left eye appears normal, and fundoscopy shows no abnormalities. Additionally, the patient experiences a loss of sensation in the right forehead. What is the most likely diagnosis?

MRCP2-3061

A 26 year-old man with ataxia telangiectasia undergoes open biopsy of an enlarged axillary lymph node. Microscopic examination reveals changes consistent with nodular sclerosing Hodgkin’s disease. Regrettably, he develops spreading cellulitis around the biopsy site which does not improve with intravenous antibiotics and ultimately necessitates surgical debridement.

What is the primary cause for the heightened vulnerability to infections in individuals with ataxia telangiectasia?