Archives: MRCP Part 2

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.

Lab results show:
– Na 138 mmol/l (135-145)
– K 4.5 mmol/l (3.5-5.5)
– Creatinine 254 micromol/l (60-90)
– GFR 28 ml/min (70 – 140)
– Calcium 2.25 mmol/ (2.1-2.65)
– Alk phos 90 IU/l (44-147)
– PTH 6.9 pmol/l (1.2-5.8)

What is the most appropriate course of action for managing osteoporosis in this patient?

MRCP2-4122

A 53-year-old man with diabetes presents with weight loss, fevers and dull, persistent left loin pain. He has been treated for relapsing urinary tract infections with oral antibiotics.

On examination, his temperature is 37.9 °C, blood pressure is 130/80 mmHg and chest and abdominal examination is unremarkable.

Investigations:
Haemoglobin (Hb) 143 g/l 135 – 175 g/l
White cell count (WCC) 18 × 109/l 4.0 – 11.0 × 109/l
Platelets (PLT) 510 × 109/l 150 – 400 × 109/l
Sodium (Na+) 145 mmol/l 135 – 145 mmol/l
Potassium (K+) 4.2 mmol/l 3.5 – 5.0 mmol/l
Urea 12 mmol/l 2.5 – 6.5 mmol/l
Creatinine (Cr) 120 μmol/l 50 – 120 µmol/l
Erythrocyte sedimentation rate (ESR) 67 mm/h 1 – 20 mm/h
Computerised tomography scan shows a heterogeneous non-enhancing mass on the left kidney, which is hydronephrotic. The right kidney is normal.
Renal biopsy shows lipid-laden macrophages with lymphocytes and polymorphonuclear leukocytes.

What is the definitive treatment in this patient?

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?

MRCP2-4102

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?

MRCP2-4103

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?

MRCP2-4104

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?

MRCP2-4105

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?

MRCP2-4106

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?

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.

MRCP2-4108

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?