Archives: MRCP Part 2

MRCP2-3575

A 50 year-old man presents to the nephrologists with chronic kidney disease. He has a medical history of hypertension, type 2 diabetes, and Parkinson’s disease, and is currently taking ramipril, metformin, and bromocriptine.

Over the past year, his glomerular filtration rate (GFR) has steadily declined from 85 to 44 ml/min/1.73m². The only symptom he reports is chronic back pain, which has been worsening over the same period. On examination, both kidneys are palpable.

Routine investigations reveal the following results:

– Hb: 12.1 g/dl
– MCV: 94.2 fl
– Platelets: 264 x10^9/l
– WCC: 7.1 x10^9/l
– Na: 137 mmol/l
– K: 4.6 mmol/l
– Urea: 13.8 mmol/l
– Creatinine: 157 mol/l
– eGFR: 44 ml/min/1.73m²
– ALT: 24 IU/l
– ALP: 78 IU/l
– Bilirubin: 6 mol/l
– Albumin: 37 g/l
– Total protein: 64 g/l
– Serum protein electrophoresis pending
– Urine dipstick negative for blood, protein, leucocytes, and nitrites

An abdominal ultrasound reveals bilateral hydronephrosis. What is the most likely cause of his chronic kidney disease?

MRCP2-3576

A 22-year-old man visited his GP after experiencing a sudden collapse while attending a comedy night. Although he did not lose consciousness, he had difficulty staying awake and is struggling with his studies. During the examination, his pulse was regular at 60 bpm, and his ECG showed normal sinus rhythm. His blood pressure was 134/70 mmHg while sitting and 125/65 mmHg while standing. What is the probable reason for his collapse?

MRCP2-3577

A 27-year-old woman presents to a neurologist for the first time after relocating to a new area. She has been referred by her primary care physician for possible migraines, which she has been treating with acetazolamide.

During her visit, she reports experiencing severe headaches that can reach up to 10/10 on the pain scale. The headaches are typically worse in the morning and improve as the day goes on. She finds relief from sitting in a chair, but can sometimes experience vomiting. Coughing and chewing hard foods exacerbate the headaches.

Upon examination, the patient has normal eye movements and her optic discs appear slightly blurred, but there are no visual field defects. She declines lying flat and is not tender over her temporal scalp. Her vital signs are normal and she has no fever. The most recent test results are provided:

– Na+ 132 mmol/l
– K+ 3.1 mmol/l
– Urea 4.2 mmol/l
– Creatinine 76 µmol/l
– HCO3 18 mmol/l
– MRI head shows no mass lesion, but there is increased subarachnoid space around the optic nerves.

What is the most appropriate course of management?

MRCP2-3578

A 42-year-old man comes to the clinic complaining of blurred vision while reading for the past few weeks. He first noticed this issue during a business trip to Germany a few years ago. He has no significant medical history and is only taking an over-the-counter pain reliever as needed.

During the examination, the left pupil is slightly larger than the right, and the reaction to light is greatly reduced, although it reacts better to accommodation. Tendon reflexes are absent, and plantars are down-going. Peripheral sensation is normal.

What is the most probable diagnosis?

MRCP2-3579

A 60-year-old woman presents to the neurology clinic with intermittent left-sided facial pain. She describes the first attack occurring a year ago while cleaning her teeth with an electric toothbrush, resulting in severe electric-shock pain in her cheek and jaw. Although symptoms resolved after receiving a filling, she has since experienced similar attacks every few weeks, sometimes unprovoked but often triggered by stimulation or cold winds. The patient is distressed by the impact on her daily life. She has a history of hypothyroidism and struggles with weight management, but no allergies or family history of neurological disease. On examination, there are no abnormalities in cranial or peripheral nerves, vision, or hearing.

What is the initial management approach for this patient’s symptoms?

MRCP2-3580

A 59-year-old man presents with severe dyspnoea at rest. He has a past medical history of motor neurone disease which was diagnosed 9 months ago. On examination his chest sounds clear. His respiratory rate is 20 breaths per minute with a shallow depth.

You perform an arterial blood gas which is as follows:

PaO2 7.1 kPa
PCO2 6.3 kPa
pH 7.32
HCO3 38 mmol/l

What is the appropriate management for this patient?

MRCP2-3581

A 72-year-old man presents to the emergency department with limb weakness and speech difficulties. He woke up with these symptoms at 7 am and was last seen by his wife at 9 pm the previous night, when he was feeling well. The patient has a medical history of hypertension and hypercholesterolemia and takes ramipril and atorvastatin. He is a non-smoker and does not consume alcohol. He is an independent individual and holds a non-executive director position in a major multinational organization.

Upon examination, the patient’s heart rate is 88 beats per minute, blood pressure is 128/67 mmHg, respiratory rate is 17/minute, oxygen saturation is 96% on room air, and temperature is 37ºC. Neurological examination reveals expressive dysphasia and 3+/5 power in the right upper and lower limbs with corresponding reduced sensation. Blood glucose testing is normal. An ECG shows atrial fibrillation.

Urgent CT head and CT angiography reveal a proximal occlusion of the anterior circulation and no haemorrhage. The patient undergoes a diffusion-weighted MRI, which shows a limited core infarct volume.

What is the optimal management plan for this patient?

MRCP2-3582

A 35-year-old migrant from Asia is referred for evaluation after a routine health check by her primary care physician. The referral notes ‘possible neurological abnormality’. She has no significant medical history, but reports a past history of working in a factory.

During the examination, you observe that her right pupil is dilated and sluggish responsive to light – both direct and consensual. Ankle reflexes are absent, even with reinforcement. Plantar reflexes are flexor.

What is the probable underlying diagnosis?

MRCP2-3583

A 53-year-old man arrives at the emergency department complaining of a persistent headache that worsens when bending down and in the morning. The headache has been ongoing for a month, and the patient has no medical history or regular medication use.

A CT scan of the head is ordered, revealing a large mass lesion on the right side that is causing displacement of the uncus of the temporal lobe under the tentorium cerebelli.

What is the earliest clinical sign that can be expected to be abnormal based on the patient’s presentation?

MRCP2-3584

A 55-year-old man presents to the Neurology Outpatient Clinic with complaints of memory loss and ataxia. He has lost 10 kg of weight over the past six months and is experiencing fatigue, watery diarrhoea, and abdominal pain. He has a medical history of osteoarthritis and hypertension. On examination, he appears tanned and is wearing loose clothing. A systolic murmur is heard over the left fifth intercostal space during cardiovascular examination. His abdomen is distended, and there is palpable pelvic lymphadenopathy. Neurological examination reveals clonus in the ankles bilaterally, and he has a broad-based stance and sways while walking. Cognitive testing shows an Abbreviated Mental Test Score (AMTS) of 8 out of 10. What is the most likely diagnosis?