Archives: MRCP Part 2

MRCP2-3004

A 45-year-old woman presents with wasting and weakness that initially affected her lower limbs and has now spread to her upper limbs. She experiences unsteadiness and clumsiness, particularly in the dark, and has numbness in her feet. These symptoms have been slowly progressing over the past decade. She reports no bladder issues and has no contact with her father, who reportedly had similar symptoms but to a lesser degree. On examination, her tone is flaccid, and there is weakness in the distal muscles of her legs, particularly in dorsiflexion and eversion of the ankles. There is also mild weakness in her arms, absent tendon reflexes, and mild blunting to pinprick over her feet bilaterally. Her cranial nerve examination is unremarkable. What is the most crucial step in investigating this patient’s condition?

MRCP2-3005

A 43-year-old man presents with a fever. He reports that it started a few days ago and he has developed a frontal, dull headache. He usually stays healthy but had a fever and joint pain a few weeks ago. During the examination, nuchal rigidity and sensory loss in the right ulnar nerve distribution were noted. Blood tests showed elevated WBC and CRP levels, while CSF analysis revealed lymphocytic pleocytosis and elevated protein levels. An ECG showed first-degree heart block. What is the most likely causative agent for this patient’s symptoms?

MRCP2-3006

A 75-year-old man presents with dysphagia and chest pain that have been progressively worsening for the past 4 months despite a trial of proton pump inhibitors. He denies any weight loss or anorexia. During examination, you observe a partial ptosis on the right side and the patient reports double vision during eye movement assessment. Sustained upward gaze worsens the ptosis. A chest x-ray is ordered:

What is the probable diagnosis?

MRCP2-3007

A 75-year-old man has come to the clinic with his daughter who is worried about his increasing confusion and forgetfulness in the past few months. The daughter also reports that her previously independent father now needs more assistance with daily activities, has lost his appetite, and experiences frequent falls. He has never smoked or consumed alcohol.

The patient’s MMSE score is 20/30. During the neurological examination of his lower limbs, there is increased tone bilaterally, 3 out of 5 (MRC scale) global weakness, lack of sensation to light touch and vibration up to the knees, brisk knee-jerks, and loss of ankle jerk reflexes and extensor plantar reflexes.

The patient’s Hb level is 110 g/L (normal range for males: 135-180), and MCV is 110 fL (normal range: 80-100). Nerve conduction studies show normal conduction velocity but reduced amplitude.

What is the most probable diagnosis?

MRCP2-3008

A 40-year-old woman presents with a severe headache that has been bothering her for the past week. She complains of left-sided pain that is excruciating and makes it difficult for her to sleep at night. The pain worsens when she lies down, and she has noticed that her nose is blocked on that side. She has been feeling achy all over for the last few days and has vomited. She has tried taking paracetamol and ibuprofen, but they have not provided any relief. She is otherwise healthy and only takes the combined oral contraceptive pill.

During the examination, she appears lethargic. Her eye movements are normal, and fundoscopy reveals no abnormalities. She can move all her limbs with a power of 5/5 and has normal reflexes. She walks with a slow but steady gait. She is coryzal and refuses to let you examine her face when you press over the frontal area.

A few days ago, she was seen in the emergency department with this headache, and the report indicated that there is a homogeneous collection of moderately enhancing material in the frontal sinus. There is no evidence of bleeding, mass effect, or hydrocephalus.

What is the most probable diagnosis?

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?

MRCP2-3012

A 12-year-old boy presents his third generalised seizure over the past 72 hours, despite recently being started on sodium valproate by a neurologist for recurrent seizures 6 weeks ago, with worsening vision at night and hearing loss bilaterally. The patient has a number of myoclonic jerks as you arrive. On examination, his heart sounds are unremarkable but you notice a tachycardia at 140 and regular. The ECG is shown below:

The patient is uncooperative to further neurological examination but you notice sluggishly reactive pupils of equal size. His mother reports that he has been educated in a special needs school for the past 5 years but had been attending the local primary school until aged 9, when he dropped further behind than his peers. What investigation would lead to the underlying diagnosis?

MRCP2-3013

A 27-year-old man presents to the emergency department with a sudden occipital headache that quickly became severe and was accompanied by vomiting. He has no regular medication use or history of recreational substance use. He has been referred to the genetics clinic due to a family history of phaeochromocytoma and kidney tumors. On arrival, he has a decreased Glasgow Coma Scale, reactive pupils, and a rigid neck. His blood pressure is elevated, and he has two cafe-au-lait spots on his trunk. Urine dip shows blood and positive leukocytes, and an ECG shows ST elevation in V1-V4. A CT scan reveals a large high attenuation signal in the left cerebellar hemisphere with surrounding edema and no mass effect. A lumbar puncture shows xanthochromia color and raised red cells. What is the likely unifying diagnosis?