Archives: MRCP Part 2

MRCP2-4111

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?

MRCP2-4116

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?

MRCP2-4104

A 27 year-old man presents to his GP with a four week history of bilateral pitting oedema of his legs up to his knees. He reports occasional puffiness around the eyes lasting a couple of hours. He denies any past medical history, rash or musculoskeletal problems. On examination, he has bilateral pitting oedema of the legs up to the knees, facial oedema and mild ascites. Blood tests reveal Na+ 135 mmol/l, K+ 3.4 mmol/l, urea 4.1 mmol/l, creatinine 71 µmol/l, albumin 18 g/l and cholesterol 11.2 mmol/l. What is the most likely cause of this patient’s symptoms?

MRCP2-4102

A 50-year-old patient with a history of rheumatoid arthritis presents to the emergency department with sudden onset severe pain in the right upper quadrant. She has been experiencing vomiting and feverishness but no diarrhea. Her ankles have been swollen for a few months, and her GP prescribed furosemide, which did not help. On examination, she has voluntary guarding and tenderness in the right upper quadrant, and pitting edema to the knee. Her blood tests show elevated creatinine and CRP levels, and her urine dip shows protein and RBCs. Based on this information, what is the most likely cause of her right upper quadrant pain?

MRCP2-4107

A 42-year-old man has been referred to the renal clinic after experiencing an episode of loin pain and passing a small renal stone two weeks ago. He had a similar episode three years ago but did not seek medical advice. Apart from these episodes, he is generally healthy.

The results of his investigations are as follows:
– Haemoglobin: 145 g/L (130-180)
– White blood cells: 7.5 ×109/L (4-11)
– Platelets: 210 ×109/L (150-400)
– Serum sodium: 137 mmol/L (137-144)
– Serum potassium: 4.2 mmol/L (3.5-4.9)
– Serum urea: 6.1 mmol/L (2.5-7.5)
– Serum creatinine: 100 µmol/L (60-110)
– Serum corrected calcium: 2.3 mmol/L (2.2-2.6)
– 24-hour urine collection: Volume 1150 ml/24 hr, Calcium 18 mmol/24 hr (2.5-7.5)
– Analysis of stone showed it to contain mostly calcium.

Initially, he was advised to increase his fluid intake, but he returned to the clinic after one month, having had two further episodes. The question now is which medication to prescribe for him.

MRCP2-4105

A 15-year-old boy presents to the renal clinic with facial and limb oedema, three days after experiencing cold symptoms. He has a history of similar episodes at ages 12 and 14, which were successfully treated with steroids. His blood pressure is currently 120/65 mmHg.

The following investigations were conducted:
– Haemoglobin: 127 g/L (130-180)
– White cell count: 8.0 ×109/L (4-11)
– Platelets: 312 ×109/L (150-400)
– Serum sodium: 135 mmol/L (137-144)
– Serum potassium: 4.2 mmol/L (3.5-4.9)
– Serum urea: 6.9 mmol/L (2.5-7.5)
– Serum creatinine: 105 µmol/L (60-110)
– 24 hour urinary protein: 7 g in 24 hours
– Urine microscopy: No white cells, no red cells, no organisms

What is the most appropriate next step in managing this 15-year-old boy?

MRCP2-4108

A 36-year-old man has been referred to the renal clinic. He experienced an episode of loin pain and passed a small renal stone two weeks ago. He had a similar episode three years ago but did not seek medical advice. Apart from these episodes, he is healthy.

The results of his investigations are as follows:
– Haemoglobin: 145 g/L (130-180)
– White blood cells: 7.5 ×109/L (4-11)
– Platelets: 210 ×109/L (150-400)
– Serum sodium: 137 mmol/L (137-144)
– Serum potassium: 4.2 mmol/L (3.5-4.9)
– Serum urea: 6.1 mmol/L (2.5-7.5)
– Serum creatinine: 100 µmol/L (60-110)
– Serum corrected calcium: 2.3 mmol/L (2.2-2.6)
– 24-hour urine collection: Volume 1150 ml/24hr – Calcium 18 mmol/24hr (2.5-7.5)

The analysis of the stone showed that it mostly contained calcium. What initial advice would you give to this man?

MRCP2-4103

A 63-year-old man with a history of type 1 diabetes and end stage renal failure presents to the renal clinic for evaluation. He has been experiencing increasing fatigue and weakness in his proximal muscles over the past few months. He is currently managed with a basal bolus insulin regimen. On examination, his blood pressure is 155/82 mmHg, pulse is regular at 70 beats per minute, and there is no ankle swelling. Proximal muscle weakness is confirmed.

Lab results:

– Hb: 101 g/l
– Platelets: 95 * 109/l
– WBC: 8.4 * 109/l
– Neuts: 5.1 * 109/l
– Lymphs: 2.1 * 109/l
– Na+: 137 mmol/l
– K+: 3.7 mmol/l
– Urea: 13.2 mmol/l
– Creatinine: 382 µmol/l
– Ca++: 2.1 mmol/l
– Bilirubin: 11 µmol/l
– ALP: 185 u/l
– ALT: 23 u/l
– γGT: 57 u/l
– Albumin: 30 g/l

Based on the patient’s presentation, you suspect secondary hyperparathyroidism. At what level of PTH would you initiate calcium and vitamin D supplementation?

MRCP2-4101

A 62-year-old woman presents to the low clearance renal clinic with a history of chronic kidney disease stage IV due to bilateral ureteric injury during a previous hysterectomy. She reports feeling well except for mild ankle swelling. Her current medications include losartan, alfacalcidol, calcium, cholecalciferol, and sodium bicarbonate. On examination, her blood pressure is 175/91 mmHg, heart rate is 92 beats per minute, and JVP is visible at 4cm with pitting edema to the ankles. Her blood tests reveal a creatinine level of 387 µmol/l and a potassium level of 5 mmol/l. Which medication should be added to manage her hypertension?

MRCP2-4106

A 56-year-old man with no prior medical history presents to the Emergency department with severe frontal headaches, double vision, and nausea. His blood pressure is 190/100 mmHg, and he has grade 4 hypertensive retinopathy with papilloedema. He has a regular pulse of 90 and is not in cardiac failure. Further investigations reveal no mass lesion or haemorrhage in his CT head, and he has LVH by voltage criteria on ECG. His haemoglobin, white cell count, platelets, serum sodium, serum potassium, and creatinine levels are within normal ranges, but he has cardiomegaly on CXR.

What is the appropriate blood pressure reduction target for the first 24-48 hours of therapy?