Archives: MRCP Part 2

MRCP2-3045

A 50-year-old man presents with diplopia, dysarthria, and difficulty swallowing. Over the next few days, he develops weakness in his upper and lower limbs, and by day four, he is unable to walk unaided. He denies any sensory symptoms or bladder disturbances and has no significant medical history. He is a non-smoker, does not drink alcohol excessively, and does not take any drugs. On examination, he has bilateral dilated and fixed pupils, binocular diplopia, and weak cough. His vital capacity is reduced, and he has lower motor neurone tetraparesis. He is hyporeflexic with normal sensation. Investigations, including blood tests, CT scan, nerve conduction studies, and EMG, are normal. What is the most likely diagnosis?

MRCP2-3016

A 75-year-old man with a history of hypertension and benign prostatic hypertrophy is brought in by ambulance after a fall. He reports feeling dizzy after standing up from his armchair, stumbled, and tripped over his cat. His wife, who witnessed the fall, reports that he then hit his head on the coffee table and lost consciousness for around 1 minute.

She describes no abnormal movements or incontinence. On regaining consciousness, he was immediately oriented. He remembers regaining consciousness. He has no headache, dizziness, nausea, or vomiting.

On examination, he has a small laceration on his forehead. His pupils were equal and reactive to light. He had no focal neurological deficits. He was a 15 on the Glasgow Coma Scale. His abbreviated mental test score was 10/10.

ECG: Sinus rhythm. 70 beats per minute. No T wave or ST segment changes.

Blood pressure (lying): 135/75 mmHg
Blood pressure (standing): 110/60 mmHg

Haemoglobin 135 g/dl
Troponin T 1 ng/L

Urine dip: trace of protein

What is the most appropriate course of action?

MRCP2-3020

A 78-year-old man with a history of prostatic carcinoma presents to the Emergency Department with complaints of lower back pain and heavy legs with reduced sensation. On examination, he has percussion tenderness of his spine, loss of sensation up to the umbilicus, a distended bladder, and reduced anal tone. He also has significantly reduced power in his lower legs, hyperreflexia, and upgoing plantar responses. What is the most suitable investigation to request?

MRCP2-3021

A previously healthy 25-year-old man is brought to the Emergency department after a car accident. He has a GCS of 7 and is intubated and ventilated. A CT scan of his head reveals a large subdural hematoma on the right side. The decision is made to transfer him to a neurosurgical center 100 miles away. However, 70 miles into the transfer, he suddenly deteriorates and is diagnosed with a tension pneumothorax. What is the best initial course of action?

MRCP2-3022

A 50-year-old man arrives at the emergency department complaining of the most severe headache he has ever experienced. He explains that he was sitting with his wife when he suddenly felt excruciating pain at the back of his head. The pain quickly escalated to a 10/10 intensity, and he also feels nauseous, although he has not vomited yet.

The patient has a medical history of adult dominant polycystic kidney disease and hypertension, for which he takes ramipril. Upon examination, his Glasgow coma scale is 15/15, and there is no focal neurology.

Due to concerns of an intracranial bleed, a non-contrast CT head is ordered, which reveals hyperdensity in the subarachnoid space and ventricles.

What is the most appropriate definitive intervention for this diagnosis?

MRCP2-3023

A 65-year-old retiree presents to the clinic with complaints of foot pain and difficulty walking. Upon further questioning, the patient reports experiencing numbness in the soles of their feet for the past year, as well as a tingling sensation and burning pain. The patient also notes weakness in their legs and unsteadiness while walking, which has led to decreased mobility. The patient does not take any regular medications but has been purchasing over-the-counter painkillers for symptom relief. They have a history of smoking 1 pack of cigarettes per day for the past 40 years and report spending more time at home since retiring.

Physical examination reveals symmetrical distal sensory loss in the lower limbs and absent ankle reflexes even with reinforcement. There is no significant postural drop in blood pressure.

Which of the following is the most appropriate next step in management?

MRCP2-3024

A 25-year-old woman, who recently got married, visits the first seizure clinic and receives a diagnosis of idiopathic generalised epilepsy. She expresses her desire to start a family in the near future. Which first-line antiepileptic medication should be avoided?

MRCP2-3025

A 35-year-old man underwent surgical removal of a compressive pituitary macroadenoma in France four weeks ago and has been receiving pituitary hormone replacement therapy since, including growth hormone. The surgery was uncomplicated, and he initially had a smooth recovery. He has no other medical history. However, he has recently developed poor balance with a broad-based gait and severe forgetfulness over the past one to two weeks. During the examination, you notice an ataxic gain and occasional myoclonic limb movements. His MMSE score is 22/30, and routine blood tests are normal. Based on the probable diagnosis, what abnormalities might you expect to see on his brain MRI?

MRCP2-3026

A 24-year-old male presents to the emergency department with a sudden onset headache. The nursing staff are concerned about the appearance of his ECG taken at triage. He denies any chest pain or shortness of breath. On examination, he appears agitated and refuses to open his eyes to light. His blood pressure is 140/80 mmHg and his heart sounds are normal. There is no visible JVP and his lung fields are clear.

What is the most probable reason for the ECG changes observed in leads V4-V6?

MRCP2-3027

A 67-year-old woman presented to her GP with sudden onset of visual disturbance in her right eye accompanied by a throbbing headache on the right side of her head. She described the visual disturbance as a moving silhouette descending from above leading to complete visual loss, which lasted for about a minute and then resolved. She also complained of pain in her jaw while chewing food and when combing her hair. This had occurred several times in the past week. The patient had a medical history of hypertension and polymyalgia rheumatica and was taking bendroflumethiazide 2.5 mg/day.

On examination, the patient was alert and oriented. Her blood pressure was 140/75 mmHg, and her pulse was 76/min and regular. She had an ejection systolic murmur radiating into the neck and no carotid bruits on cardiovascular examination. Fundoscopy examination revealed bilateral silver wiring and AV nipping. The right temporal/jaw area appeared tender and pulsatile. Peripheral nervous system examination was normal.

Investigations showed that the patient had a low haemoglobin level, high platelet count, and high ESR (Westergren). Carotid Dopplers revealed that the left internal carotid artery had 100% stenosis, while the right internal carotid artery had less than 50% stenosis. The patient’s cholesterol level was high, and her other blood test results were within normal limits.

What is the likely diagnosis for this patient?