MRCP Part 2 Archive - Page 67 of 479

MRCP2-4132

A 65-year-old man presents with anuria and lower back pain that has been ongoing for 24 hours. He is currently taking bendroflumethiazide 2.5 mg for hypertension and is otherwise healthy, although he is awaiting an appointment for urinary frequency, urgency, and dribbling. Upon investigation, his potassium levels are found to be elevated at 6.5 mmol/l. After administering iv insulin and dextrose, his potassium levels have decreased to 5.4 mmol/l, and he has been catheterized. What is the most appropriate next step in management?

MRCP2-4133

A 72-year-old dialysis-dependent woman is brought to the emergency department with complaints of difficulty breathing. Her husband reports that she had chest pains the previous night before going to bed.

Upon examination, her respiratory rate is 28, her JVP is elevated, and coarse crepitations are heard throughout both lung fields. Urgent U&Es show:

– Serum sodium 138 mmol/L (135-146)
– Serum potassium 4.2 mmol/L (3.5-5.0)
– Chloride 109 mEq/L (97-107)
– Urea 23.8 mg/dL (10-20)
– Creatinine 812 μmol/L (79-118)

The patient reports not passing any urine, making it impossible to provide a specimen for urinalysis. An ECG shows sinus rhythm and anterolateral ischaemic changes, while a chest x-ray reveals marked interstitial oedema in both lungs.

What is the most appropriate management to address the patient’s shortness of breath?

MRCP2-4134

A 25-year-old woman presents to your clinic, referred by her yoga instructor. She is typically in good health and is currently in the midst of a 4-week yoga teacher training program. She has noticed dark urine for the past few days and is concerned that she may have a serious condition. She describes the urine as the color of iced tea. She denies having a fever and has no other complaints or discomfort aside from the dark urine.

The patient appears to be in good physical condition and is not in any obvious distress. Her vital signs are within normal limits, with a temperature of 37.0 °C, blood pressure of 110/70 mmHg, and a pulse of 70 bpm. Her extremities are non-tender and non-edematous, and the rest of her physical exam is unremarkable.

The following laboratory results are obtained:
– Creatinine (Cr): 180 µmol/l (normal range: 50 – 120 µmol/l)
– Urea: 12.0 mmol/l (normal range: 2.5 – 6.5 mmol/l)
– Hemoglobin (Hb): 130 g/l (normal range: 135 – 175 g/l)
– Potassium (K+): 4.2 mmol/l (normal range: 3.5 – 5.0 mmol/l)
– White cell count (WCC): 8 × 109/l (normal range: 4.0 – 11.0 × 109/l)

What would be the most appropriate initial test to perform for further evaluation?

MRCP2-4135

A 67-year-old man with IgA nephropathy is being seen in the renal dialysis clinic for the first time. He is nearing stage 4 kidney disease and his doctor is preparing him for dialysis soon. Due to past abdominal surgeries, peritoneal dialysis is not an option. What is the preferred initial choice for vascular access for routine haemodialysis?

MRCP2-4136

A 35 year old female patient visits the endocrinology clinic for a follow-up appointment. She complains of excessive thirst and drinking a lot of water for the past year. Despite having normal fasting glucose and oral glucose tolerance test results, the patient underwent a water deprivation test during her last visit. The results are as follows:

Time Urine osmolality (mOsm/kg) Serum osmolality (mOsm/kg) Weight (kg) % change in weight
0800 263 263 86.1 n/a
1000 265 278 85.7 -0.46%
1200 279 289 85.4 -0.81%
1400 280 295 84.9 -1.39%
1600 285 301 84.6 -1.74%
1700 DDAVP given – –
1800 286 302 84.3 -2.09%
2000 289 303 84.1 -2.32%

What is the underlying cause of this woman’s symptoms?

MRCP2-4137

You are summoned to attend to a 35-year-old man who experienced haematemesis while on the dialysis ward. His haemoglobin level has decreased from 101g/L to 69g/L. He has a blood pressure of 98/54 mmHg and a heart rate of 100 bpm. The patient is presently waiting for a renal transplant due to end-stage diabetic nephropathy. He has no previous medical history. You arrange for an immediate OGD. What is your plan for managing his anaemia?

MRCP2-4138

A 59-year-old woman with a history of systemic lupus erythematosus (SLE) has been admitted to the renal ward due to deteriorating renal function. Her laboratory results are as follows:

– Sodium: 137 mmol/L (135 – 145)
– Potassium: 5.0 mmol/L (3.5 – 5.0)
– Bicarbonate: 16 mmol/L (22 – 29)
– Urea: 19.2 mmol/L (2.0 – 7.0)
– Creatinine: 429 µmol/L (55 – 120)

The renal team has conducted a renal biopsy and found a ‘Wire-loop’ appearance with endothelial and mesangial proliferation consistent with diffuse proliferative glomerulonephritis. The patient has responded well to high-dose methylprednisolone in terms of her renal function.

What is the most appropriate maintenance treatment for this patient?

MRCP2-4139

A 36-year-old woman presents to the respiratory clinic after a CT scan revealed a pulmonary nodule. She was hospitalized two months ago for aspiration pneumonia and received intravenous antibiotics. A chest X-ray showed consolidation on the left side, and she was treated for alcohol withdrawal. After three days, she was discharged with oral antibiotics and community alcohol liaison services. Her GP ordered a repeat chest X-ray six weeks later, which showed persistent consolidation. A CT chest was then performed, revealing a 5 mm pulmonary nodule on the right side. What is the appropriate course of action for investigating or monitoring this nodule?

MRCP2-4109

A 30-year-old woman with a history of SLE is experiencing the nephrotic syndrome. Upon performing a renal biopsy, it is confirmed that she has diffuse proliferative glomerulonephritis (WHO Class IV). What treatment plan would you recommend for her?

MRCP2-4114

A 23-year-old man, who is typically healthy, has been referred to the hospital by his general practitioner. He is experiencing blurred vision and headaches that have persisted for the past two days. Upon further questioning, the patient reveals that he has not been urinating much and has noticed difficulty breathing during physical activity. Although he did fall and injure his leg three days ago, he has not left his house since then and denies any chest pain.

During the examination, the patient’s pulse is regular at 110/minute, and his blood pressure is high at 200/120 mmHg. He has a JVP of 5cm, and his heart sounds are normal. Upon auscultation of his chest, fine basal crepitations are heard, and his respiratory rate is 22/minute with a sighing pattern. He has oedema on his right leg and side, but his abdomen is soft and non-tender with no masses. Fundoscopy reveals no abnormalities.

After inserting a urinary catheter, it is discovered that the patient has a residual volume of 50 mls of dark urine. Urinalysis shows blood+++ and protein++. Microscopy reveals no organisms, but scanty hyaline casts with fewer than 10 red blood cells per high-powered field.

Further investigations reveal abnormal levels in the patient’s serum sodium, potassium, urea, creatinine, calcium, phosphate, and bicarbonate. Specifically, his serum potassium level is 6.8 mmol/L (3.5-4.9), which requires immediate treatment.

What is the appropriate treatment to correct the patient’s high potassium levels?