A 15-year-old boy is brought to the emergency department by his mother after experiencing brief episodes of unresponsiveness while walking. He has no memory of these episodes. At the age of 10, he was diagnosed with absence seizures and was prescribed anti-epileptics. These were gradually discontinued by his neurologists two years ago after being seizure-free for three years.
In the last 48 hours, he has had four of his typical absences. As a healthcare provider, you decide to prescribe an anti-epileptic. What antiepileptic medication should you avoid?
MRCP2-3052
A 33-year-old woman with no prior history of seizures is referred to the neurology team after experiencing two episodes. The team prescribes carbamazepine, but three weeks later, she has several more seizures despite being fully compliant with the medication. She has a medical history of asthma and gastro-oesophageal reflux disease, for which she uses salbutamol and beclometasone inhalers, montelukast, cimetidine, and omeprazole. Additionally, she takes the combined oral contraceptive pill. Which of these medications may have contributed to the recurrence of her seizures?
MRCP2-3054
A 55-year-old woman presents with a persistent headache that has lasted for 4 months. She recently experienced a discharge from her left ear, which was diagnosed as Aspergillus fumigatus and treated with eardrops. However, she now reports double vision and sciatic pain in her left leg. She has a history of breast cancer and is currently taking Tamoxifen. On examination, she has bilateral papilloedema, paretic lateral recti, and a mild facial paresis on the left side. Her ankle jerk is hypoactive and planters are flexors on both sides. Further investigations reveal scattered leptomeningeal enhancement on an MRI brain scan and elevated levels of ALT and ESR. The CSF analysis shows elevated protein and lymphocytes, but no malignant cells or evidence of infection. What is the most likely diagnosis?
MRCP2-3055
You assess two new patients in the Cerebrovascular Clinic. Mrs X is a 70-year-old woman with background hypertension. She has had one episode of presumed left amaurosis fugax one week previously. Carotid Doppler ultrasound scanning shows a 76% stenosis of the left internal carotid. Mr Y is a 74-year-old man with stable angina and peripheral vascular disease. Three days previously he had a transient episode of dysphasia lasting 20 min. Carotid Doppler ultrasound scanning shows a 75% stenosis of the left internal carotid. Who would benefit most from carotid endarterectomy?
MRCP2-3056
A 50-year-old woman visited her GP with complaints of tingling in her right palm and pain in her right wrist. She had been experiencing these symptoms on and off, but they had recently become severe enough to keep her up at night. She had also noticed a decrease in her grip strength, making it difficult for her to work at the checkout counter in her local supermarket. Apart from these symptoms, she felt fine and had not experienced any weakness in her lower limbs or other hand.
The patient had a stable weight and denied any issues with her neck or swallowing. She had a medical history of hypothyroidism and hypertension and was taking regular medication for these conditions. She was a non-smoker and only drank alcohol occasionally.
During the examination, the patient appeared alert and oriented. Her fundoscopy and cranial nerve examination were normal, and she had full neck movements. However, there was wasting over the right thenar eminence and fasciculations with a small burn over the right index finger. No other fasciculations were detected in the proximal limb or other hand. Tone appeared normal, and reflexes were intact. There was weakness of thumb abduction and opposition, with loss of pinprick and light touch sensation over the thumb, index, and middle finger in the right hand. No abnormalities were found during the examination of the lower limb.
Nerve conduction studies revealed an absent sensory action potential in the right median palmar branches and denervation of the right abductor pollicis brevis. Sensory and motor conduction studies in the left upper limb and lower limbs were normal.
What is the most likely diagnosis?
MRCP2-3057
A 16-year-old girl was referred to a neurologist due to experiencing multiple episodes of collapse. According to her mother, these episodes lasted from a few seconds to one minute, during which the girl would suddenly collapse and become limp. In the past month, she had experienced one episode during an argument with her boyfriend, another while watching football on TV, and another while laughing with her sister. During one of these episodes, she also had visual hallucinations. The patient claimed that she had never lost consciousness during these episodes, but she did report feeling unable to move several times after waking up in the morning. What is the most probable diagnosis?
MRCP2-3058
A 58-year-old male construction worker presents with sudden and severe lower back pain. He has no history of orthopedic issues and has been in good health until now. The patient reports experiencing tingling sensations in his lower limbs and has not been able to urinate since the onset of the pain. Upon neurological examination, weakness (3/5 of both lower limbs) and loss of sensation to touch in L4, L5, and S1 are observed. Vibration sensation and joint position sensation are intact, but reflexes in the ankles and knees are absent and the plantar response is uncertain. The patient’s blood pressure is 160/70 in his left arm and 152/64 in his right, heart rate is 96 bpm, temperature is 37°C, and ECG shows normal sinus rhythm with no signs of ischemia. The rest of the examination is unremarkable. What diagnostic test would be most helpful in determining the cause of the patient’s symptoms?
MRCP2-3059
A 26-year-old male patient complains of abrupt onset of pain on the right side of his neck, accompanied by pain behind his right eye. After 12 hours, he experiences right ptosis and miosis of his right pupil, along with left-sided weakness and facial drooping. What could be the probable cause of his stroke?
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?