A 59-year-old woman was admitted to the hospital due to increasing thirst and abdominal pain. She had a history of breast cancer and underwent a radical mastectomy three years ago. Upon investigation, her serum corrected calcium level was found to be 3.5 mmol/L (2.2-2.6) and her serum alkaline phosphatase level was 1100 IU/L (45-105). Despite receiving 4 liters of 0.9% saline intravenous infusion, her serum calcium remained elevated. What is the most appropriate next step in her management?
MRCP2-4112
An 81-year-old male is brought to the Emergency department by his family. He had an ‘upset stomach’ earlier in the week with profuse diarrhoea. This has now settled but he remains lethargic, and generally feels weak.
His past medical history is significant for hypertension, type 2 diabetes mellitus (diet controlled) and chronic obstructive pulmonary disease. He is maintained on lisinopril 20 mg OD, metformin 1000 mg BD, and salmeterol/fluticasone inhaler BD. He has continued taking his medication during this episode. On examination he is pale and looks unwell.
Gastrointestinal and cardiorespiratory examination are unremarkable besides a resting tachycardia of 100 beats / minute.
What is the most important step in treating his hyperkalaemia?
MRCP2-4113
You admit a 49-year-old man who is on daily peritoneal dialysis in his own home. He noticed that his PD fluid looked cloudier than usual this morning. What is the most effective treatment for the cause of his presentation?
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?
MRCP2-4115
A 42-year-old woman with a history of multiple urinary tract infections, who currently has a Foley catheter in place, presents to the Emergency Department with complaints of fatigue and a fever that started last night. Upon examination, her temperature is 38.5 °C. A urine sample collected by her primary care physician the day before shows a significant growth of E. coli. The urine in the catheter bag appears cloudy. Her white blood cell count is within normal limits, but her C-reactive protein (CRP) level is elevated at 90 mg/L.
What is the most appropriate course of action for this patient?
MRCP2-4116
A GP contacts the renal registrar seeking guidance on a patient. The doctor is treating a 63-year-old man with renal disease caused by type 1 diabetes mellitus. The patient is currently taking enalapril, aspirin, simvastatin, and insulin. He is experiencing pain in his right big toe, and the GP suspects it may be gout but is uncertain about the appropriate medication to prescribe. The patient’s vital signs are normal, and routine renal function tests conducted last week have been stable for the past six months. The results are as follows: Laboratory value Value Normal Range Serum creatinine 200 µmol/litre 60-110
Which medication should the GP recommend?
MRCP2-4117
A 25-year-old man presents with facial swelling and ankle edema. He had a flu-like illness with a productive cough two weeks ago. His mother reports that he had a similar episode of swelling five years ago, but it resolved after treatment. His previous U&E results were normal and he did not have a rash. On examination, there is no fever or rash. He has pitting edema up to his knees. Initial investigations show: s Albumin 32 g/l 35 – 55 g/l Urea 4.5 mmol/l 2.5 – 6.5 mmol/l Creatinine (Cr) 70 μmol/l 50 – 120 µmol/ Sodium (Na+) 142 mmol/l 135 – 145 mmol/l Potassium (K+) 3.8 mmol/l 3.5 – 5.0 mmol/l Urinalysis Protein +++ 24h urine collection 2.8 g protein What is the best initial treatment for his likely diagnosis?
MRCP2-4118
A 35-year-old woman is admitted to the hospital with an acute exacerbation of her asthma. During her stay, she complains of left flank pain that radiates to her groin and painful urination. The following test results are obtained:
– Sodium (Na+): 140 mmol/l (normal range: 135-145 mmol/l) – Potassium (K+): 4.5 mmol/l (normal range: 3.5-5.0 mmol/l) – Urea: 5.8 mmol/l (normal range: 2.5-6.5 mmol/l) – Creatinine (Cr): 70 μmol/l (normal range: 50-120 µmol/l) – Urinalysis: Hexagonal crystals – Kidney-ureter-bladder (KUB) X-ray: Suspicious area of a renal stone calculus seen in the region of the left vesico-ureteric junction
The patient passes the stone and is diagnosed with cystinuria. She is advised on dietary changes, urine alkalinization, and adequate hydration therapy before being discharged. However, she returns a few weeks later with similar symptoms.
What is the next best course of medical treatment?
MRCP2-4119
A 65-year-old patient with chronic kidney disease related to hypertension presents to the clinic. He is managed with a number of anti-hypertensive medications and once-daily insulin to control his blood sugar. He also takes simvastatin and clopidogrel. On examination, his BP is 150/90 mmHg, pulse is 75 bpm and regular. His chest and abdominal examination are unremarkable. Investigations reveal the following: Haemoglobin (Hb) 120 g/l 130–170 g/l White cell count (WCC) 6.2 × 109/l 4.0–11.0 × 109/l Platelets (PLT) 180 × 109/l 150–400 × 109/l Sodium (Na+) 137 mmol/l 135–145 mmol/l Potassium (K+) 4.8 mmol/l 3.5–5.0 mmol/l Creatinine (Cr) 180 μmol/l 50–120 μmol/l Corrected calcium (Ca2+) 2.3 mmol/l 2.2–2.7 mmol/l Phosphate (PO43-) 1.2 mmol/l 1.12–1.45 mmol/l Parathyroid hormone (PTH) 8.5 pmol/l 0.9–5.4 pmol/l What is the most appropriate treatment for this patient?
MRCP2-4121
A 72-year-old woman with a history of left hip and right Colles’ fracture presents to the rheumatology clinic for evaluation. She has been prescribed risedronate by her GP for bone protection, but has been experiencing worsening reflux oesophagitis in recent months. Her medical history includes hypertension, previous treatment for thyrotoxicosis with radioiodine, and smoking 10 cigarettes per day. On examination, her BP is 123/82, pulse is regular at 75, and BMI is 21.