Archives: MRCP Part 2

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?

MRCP2-3028

A 70-year-old man is brought to the emergency department after a fall. His daughter found him unresponsive on the floor after hearing a loud noise. The patient’s daughter reports that he has been unsteady on his feet for the past few days and is recovering from a urinary tract infection. The patient has a medical history of benign prostatic hyperplasia and atrial fibrillation, for which he takes tamsulosin, finasteride, and rivaroxaban.

Upon examination, the patient is drowsy with a GCS of 12 (E3V4M5). His heart rate is 85 bpm, and his blood pressure is 210/118 mmHg. His chest is clear with normal heart sounds upon auscultation. Oxygen saturations are 90% on air. The patient has a deep laceration over the left side of his forehead, which is oozing blood, and there is bruising down the left side of his body. Pupils are equal and reactive to light.

A CT scan of the head reveals evidence of a moderate intracranial hemorrhage in the left frontal lobe, with no evidence of a mass effect.

What is the most appropriate next step in managing this patient?

MRCP2-3029

A 75-year-old man presents to the Emergency department with weakness affecting both legs. The weakness had been preceded by a sudden onset of left sided hip pain, which had become intractable over the last four hours. He had also developed numbness over both legs to the level of the sternum. He had a past medical history of hypertension and ischaemic heart disease and took atenolol and Suscard buccal when required. He was a smoker of 10 cigarettes per day and drank a whiskey a night.

On examination, he appeared in distress. What is the likely cause for this patient’s symptoms?

MRCP2-3009

A 70-year-old woman presents with a gradual onset of severe frontal headache and double vision over the past 24 hours. Apart from this, her medical history is unremarkable. During the examination, it is observed that her right eye has partial ptosis, and the pupil is resting outwards and downwards with a sluggishly reacting dilated pupil. Additionally, there is a failure of intorsion of the right eye. The patient’s neurological and physical examination is otherwise normal, and routine blood tests and plain CT head are also normal. What is the most crucial investigation that needs to be conducted next?

MRCP2-3010

A 30-year-old man comes to the clinic complaining of anorexia, feverishness, and vertigo that have been going on for four days. He reports having difficulty balancing and staying upright when walking and experiencing mild vertigo episodes lasting 10-20 minutes. His hearing is unaffected, and he has cervical lymphadenopathy. Other than that, the examination is normal. What is the probable diagnosis?

MRCP2-3011

A 67-year-old male presents to the emergency department via ambulance after experiencing his first seizure, witnessed by his wife. She reports sudden onset limb jerking lasting for approximately 5 minutes, accompanied by urinary incontinence and tongue biting. The patient experienced confusion and drowsiness immediately after the seizure. He has no prior history of seizures, no significant medical history, and does not take any medications. However, his wife reports that he has been acting differently over the past four weeks, displaying extreme agitation and occasional paranoia. She attributes this to his recent complaints of flu-like symptoms, including headaches, muscle aches, and a non-productive cough.

Upon examination, the patient exhibits significant gait and limb ataxia, but no truncal ataxia. Blood tests are unremarkable except for positive anti-NMDA antibodies. An MRI scan reveals swelling in bilateral limbic cortices, but no other intracranial abnormalities. The patient has declined a lumbar puncture and is deemed to have capacity.

What diagnostic test is most likely to provide the underlying diagnosis?