A 50-year-old man presents to ambulatory care with bilateral leg swelling and proteinuria on urine dipstick. He has no significant medical history and works as a librarian. Two weeks ago, he had a throat infection and joint pain which was treated with penicillin by his GP. He has been experiencing some arthralgia and myalgia since then. On examination, he has bilateral pitting oedema to the knees, but no other significant findings. His blood tests reveal low Hb and albumin levels, elevated CRP, and mildly elevated complement C3 and C4 levels. He undergoes further testing, including a renal biopsy which shows thickened basement membranes with subepithelial deposits on electron microscopy. Based on these findings, what is the most likely cause of his membranous glomerulonephritis?
MRCP2-4099
A 48-year-old patient with a history of rheumatoid arthritis presents to the emergency department with left flank pain and bloody urine. What is the probable cause of her symptoms?
MRCP2-4100
A 42-year-old woman presents with a headache, generalised aches and pains, lethargy and fevers. She has a medical history of type one diabetes and end-stage renal failure, and underwent a simultaneous pancreas-kidney transplant ten months ago. Four months ago, she was admitted with neutropaenia which led to the early cessation of her valganciclovir and a reduction in her immunosuppression. On examination, she appears pale, lethargic and unwell. Her temperature is 39.4 degrees Celsius, her pulse is 115 beats per minute and regular, her blood pressure is 102/59 mmHg, her respiratory rate is 22 breaths per minute and her oxygen saturations are 95% on room air. What is the most likely diagnosis?
MRCP2-4097
A 19-year-old male presents to the Emergency Department with complaints of blood in his urine for the past day. Initially, he noticed a few drops of dark blood at the end of urination, but it has progressively worsened, and he is now passing large amounts of cola-colored urine. He also reports swollen ankles and puffy eyes that developed over the last few hours, along with increasing lethargy and feeling unwell for the past two days. The patient denies shortness of breath, chest pain, haemoptysis, previous haematuria, or changes in urine volume. He has no past medical history of renal problems, but his brother was prescribed steroids for leaky kidneys at the age of nine. The patient has no significant drug history, except for a recent course of phenoxymethylpenicillin for tonsillitis and amoxicillin for acute sinusitis six months ago.
Upon examination, the patient is a young athletic male with a blood pressure of 162/84 mmHg, heart rate of 96 bpm, respiratory rate of 18/min, oxygen saturations of 95% on air, and temperature of 37.1 Celsius. Cardiovascular examination reveals normal heart sounds, a JVP of 3cm, and bilateral pitting oedema of his ankles. Respiratory and gastrointestinal examinations are unremarkable. The patient has bilateral periorbital oedema, but ENT and neurological examinations are normal.
Initial investigations reveal a Hb of 132 g/l, platelets of 428* 109/l, WBC of 14.2 * 109/l, ESR of 26 mm/hr, Na+ of 138 mmol/l, K+ of 5.2 mmol/l, urea of 6.4 mmol/l, creatinine of 77 µmol/l, CRP of 18 mg/l, bilirubin of 18 µmol/l, ALP of 82 u/l, ALT of 21 u/l, protein of 78 g/l, and albumin of 39 g/l. Chest x-ray shows a normal appearance of heart and lung fields, and ECG reveals sinus tachycardia of 108 bpm. Urinalysis shows blood ++++ and protein ++++, with ketones + and negative for all other parameters. Urine and blood MCS results are pending.
What is the most likely diagnosis?
MRCP2-4098
A 45-year-old man with end-stage chronic kidney disease presents to the Emergency Department with a swollen right arm. He undergoes dialysis 3 times per week through a fistula in the right arm, but has experienced pain during the last two sessions, causing him to stop 30 minutes early on both occasions. He denies any swelling in other areas of his body, shortness of breath, or fevers. His medical history includes reflux nephropathy and hypertension, and he has been receiving dialysis through the fistula for 2 years. The swelling has been developing over the past 2 weeks.
Upon examination, his heart rate is 83 beats per minute, blood pressure is 157/94 mmHg, temperature is 36.8 ºC, and oxygen saturations are 98% on air. The patient’s right arm is diffusely swollen with no erythema, and the fistula site is clean with recent evidence of needle marks and no discharge. There is a palpable thrill and an audible bruit. His chest is clear, and JVP is 2cm. There is no edema in the contralateral arm, but mild edema is present in both feet.
A chest x-ray reveals mild chronic cardiomegaly with clear lung fields. Blood results show a hemoglobin level of 105 g/l, platelets at 170 * 109/l, WBC at 9 * 109/l, neutrophils at 5.5 * 109/l, lymphocytes at 2.2 * 109/l, and CRP at 18 mg/l. His sodium level is 135 mmol/l, potassium level is 5.1 mmol/l, urea level is 21 mmol/l, and creatinine level is 753 µmol/l.
What is the most likely diagnosis?
MRCP2-4094
A 23-year-old male presents with severe abdominal pain in his left flank area going down into his groin. The pain is constant and he feels nauseated. He had a similar episode six months ago which resolved with conservative management. On examination, he has left renal angle tenderness but otherwise a soft non-tender abdomen. Investigations reveal a single solitary area of calcification within his left kidney. He is treated conservatively and subsequently seen in the renal clinic where he undergoes further investigations. Which therapeutic option is most likely to prevent future episodes?
A 57-year-old male presents to the Medical Admission Unit with a five-day history of shortness of breath that has progressively worsened. He experiences significant orthopnoea and paroxysmal nocturnal dyspnoea. His medical history includes angina, hypertension, hypercholesterolaemia, and a transient ischaemic attack three years ago. He has been seeing his GP for poor blood pressure control and was recently started on ramipril. He smokes 40 cigarettes per day and consumes 38 units of alcohol per week. On examination, he is short of breath at rest with a respiratory rate of 26/min and oxygen saturations of 92% on air. His blood pressure is 158/78 mmHg and heart rate 54 bpm. Initial investigations reveal bilateral pulmonary oedema, normal heart diameter, and the presence of aortic stenosis with a pressure gradient of 18 mmHg. What is the most appropriate next investigation to determine the cause of this patient’s symptoms?
MRCP2-4090
A 70-year-old retired plumber presents to the emergency department with recurrent urinary tract infections. He has been treated by his GP four times in the last six months with this complaint, with trimethoprim twice and a further two courses of amoxicillin. He is confused on this presentation and is will not comply with a full neurological examination. His past medical history includes a stroke and a known gastric ulcer. An ultrasound of his renal tract did not reveal any structural defects of hydronephrosis. His son reveals that he is under investigation for a possible haematological malignancy, and had a bone marrow biopsy two days ago. On examination, his heart rate is 115/min, respiratory rate 18/min, blood pressure 134/89 mmHg. His respiratory, cardiovascular and abdominal examinations are all unremarkable, other than a soft ejection systolic murmur. He has a tender prostate. His blood reveal:
A chest x-ray demonstrates bilateral coalescent airspace opacification.
A renal biopsy is undertaken, which demonstrates linear IgG deposits along the basement membrane.
What is the appropriate treatment for the likely diagnosis?
MRCP2-4089
A 28-year-old woman with a history of type 1 diabetes presents to the hospital with sudden onset abdominal pain and vomiting. Upon examination, she displays tachycardia and hypotension with diffuse abdominal tenderness.
Initial blood tests reveal:
– pH 7.25 (7.35 – 7.45) – pO2 12.1 kPa (11 – 14.4) – pCO2 5.7 kPa (4.6 – 6.4) – Sodium 138 mmol/L (135 – 145) – Potassium 4.5 mmol/L (3.5 – 5.5) – Chloride 99 mmol/L (95 – 108) – Bicarbonate 13 mmol/L (22 – 29) – Glucose 26.9 mmol/L (4 – 7) – Lactate 3.9 mmol/L (0.5 -2.2) – Ketones 5.1 mmol/L (< 0.6)
She is admitted to the endocrinology ward and started on a fixed-rate insulin scale. However, after two days of treatment, she still reports feeling unwell.
A repeat arterial blood gas is taken, revealing:
– pH 7.28 (7.35 – 7.45) – pO2 11.3 kPa (11 – 14.4) – pCO2 4.7 kPa (4.6 – 6.4) – Sodium 150 mmol/L (135 – 145) – Potassium 3.0 mmol/L (3.5 – 5.5) – Chloride 114 mmol/L (95 – 108) – Bicarbonate 23 mmol/L (22 – 29) – Glucose 6.9 mmol/L (4 – 7) – Lactate 1.9 mmol/L (0.5 -2.2) – Ketones 0.5 mmol/L (< 0.6)
What is the most probable cause of this patient’s presentation?