Archives: MRCP Part 2

MRCP2-4092

A 29-year-old man presents to the nephrology clinic for review. He was diagnosed with autosomal dominant polycystic kidney disease at the age of 20 after undergoing screening. His father, aunt, and sister also have the condition. He is currently taking ramipril 10mg daily and reports no symptoms. His blood pressure is 120/70 mmHg.

Recent blood tests reveal a decline in his eGFR from 90 mL/min/1.73 m² to 65 mL/min/1.73 m² over the past year. A recent ultrasound scan shows bilateral renal cysts, with both kidneys increasing in size from 12 cm to 14cm since the previous scan two years ago.

What treatment options should be considered for this patient?

MRCP2-4084

A 24-year-old woman with sickle cell anaemia and recurrent crises presents with blood in her urine and left-sided loin pain. She was initially treated for a urinary tract infection with nitrofurantoin by her GP. On examination, she is tender in the left loin and has a heart rate of 120 beats per minute, respiratory rate of 22/min, and temperature of 37.5ºC. Her urine is red with brown sediment, and she passes it with shaking but remains conscious. Further investigations reveal red cell casts and sloughed tissue of medullary cell in urine microscopy and rings seen in medulla on ultrasound KUB. Based on these findings, what is the likely diagnosis?

MRCP2-4083

A 59-year-old woman presents with vomiting, confusion, and lethargy. She has not sought medical attention for many years, but has a history of using co-proxamol for arthritis and takes a diuretic for hypertension. On examination, she has hyper-reflexia, nystagmus, and clonus, and her blood pressure is 165/85 mmHg. There is also evidence of vaginal bleeding. Her blood tests show elevated levels of urea, creatinine, and potassium. What is the most likely diagnosis for this patient?

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?

MRCP2-4085

A 54-year-old man with a history of hypertension treated with enalapril and diuretics complains of right flank pain. His blood pressure is 145/95 mmHg and temperature is 37.2°C. During examination, tenderness is noted in the right costovertebral angle and both kidneys are enlarged. Micro-haematuria is detected on urine dipstick. What is the most suitable next step in the diagnosis process?

MRCP2-4087

A 70-year-old man presents to the emergency department with frank haemoptysis. He has no past medical history. He smokes 20 cigarettes daily.

Observations:

Spo2 95% on room air
Respiratory rate 18/minute
Temperature 37 C
Blood pressure 101/65 mmHg
Heart rate 88 beats per minute

The examination is unremarkable.

Bloods:

Hb 82 g/L Male: (135-180)
Female: (115 – 160)
Platelets 189 * 109/L (150 – 400)
WBC 4.2 * 109/L (4.0 – 11.0)
Na+ 138 mmol/L (135 – 145)
K+ 5.1 mmol/L (3.5 – 5.0)
Urea 14.2 mmol/L (2.0 – 7.0)
Creatinine 302 µmol/L (55 – 120)
CRP 55 mg/L (< 5) Urinalysis: Blood +++
Protein +++
Glucose -ve
Leucocytes -ve
Nitrites -ve

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?

MRCP2-4088

A 54-year-old male with a history of systemic lupus erythematosus presents to the emergency department with a 5-day history of high-grade fever and productive cough. He recently travelled to Italy with his wife and has been feeling unwell ever since he got back home.

His medication history included prednisolone 10mg daily, and hydroxychloroquine 200 mg twice daily which he has been taking for the last 10 years. He is additionally on once-yearly zoledronic acid and occasional ibuprofen.

On examination, he has a temperature of 38.8°C and a pulse of 120 bpm which is regular and low volume. His blood pressure in 90/60 mmHg and he has cold peripheries. He has a confluent rash on his cheeks with nasolabial sparing. Examination of his respiratory system reveals crackles in the left lower lobe. The remaining physical examination is essentially unremarkable.

Laboratory investigations reveal:

Hb 105 g/dl
MCV 90 fl
MCH 26 pg (27 – 32 pg)
WBC 20 * 109/l
Plt 400 * 109/l
Urea 16.5 mmol/l
Creatinine 310µmol/l
Na+ 130 mmol/l
K+ 4.2 mmol/l
Albumin 30g/l

Urine dipstick shows protein 2+

Urinary electrolytes reveal:

Urinary specific gravity 1.035 (1.010 – 1.020)
Urinary osmolality (mOsm/kg) 700 (350 – 500)
Urinary sodium (mmol) 10 (20 – 40)
FeNa 0.5% (1%)

What is the most appropriate initial management option?

MRCP2-4086

A 65-year-old woman with a history of Alzheimer’s disease presents with a 4-day history of increased confusion, lower abdominal pain, and foul-smelling urine. Upon admission, her blood tests reveal:

– Hemoglobin (Hb): 119 g/l
– Platelets: 425 * 109/l
– White blood cells (WBC): 15.9 * 109/l
– Neutrophils (Neuts): 13 * 109/l
– Lymphocytes (Lymphs): 2 * 109/l
– Eosinophils (Eosin): 0.02 * 109/l
– Sodium (Na+): 136 mmol/l
– Potassium (K+): 3.7 mmol/l
– Urea: 7.2 mmol/l
– Creatinine: 78 µmol/l
– C-reactive protein (CRP): 140 mg/l

She is started on treatment for a urinary tract infection. Two days later, her blood tests show:

– Hb: 115 g/l
– Platelets: 360 * 109/l
– WBC: 10.2 * 109/l
– Neuts: 7.5 * 109/l
– Lymphs: 1.5 * 109/l
– Eosin: 0.001 * 109/l
– Na+: 141 mmol/l
– K+: 5.2 mmol/l
– Urea: 8 mmol/l
– Creatinine: 105 µmol/l
– CRP: 43 mg/l

Which antibiotic is likely to have been used to treat her UTI?

MRCP2-4070

A 50-year-old man with end stage renal failure is scheduled for haemodialysis today. He has been receiving 3 sessions a week without any complications. However, he has been experiencing shortness of breath at night and a frothy cough for the past week.

During the examination, the man has crepitations in both lungs and swollen ankles. He feels nauseous but has not vomited. His skin appears sallow with pale conjunctiva. A systolic murmur is present, and no sounds are heard over his arteriovenous fistula located in the left forearm. He is saturating at 96% in air with a respiratory rate of 21/minute.

The man’s laboratory results show Na+ at 130 mmol/l, K+ at 5.2 mmol/l, urea at 21.1 mmol/l, creatinine at 420 µmol/l, and Hb at 96g/dl. His ECG shows ST elevation in V1-V2 and tall T-waves in V4-V6.

What is the reason why the man cannot undergo haemodialysis today?

MRCP2-4069

A 70-year-old man presents to the Emergency Department with worsening shortness of breath over the last four days. He denies any history of angina or orthopnoea and denies any recent fever. He has a slight cough over the last week and yesterday noted a small amount of blood in his otherwise clear sputum. His past medical history includes type two diabetes mellitus for which he takes metformin and gliclazide. On a more detailed systems review, he admits to feeling generally run down over the last week and has noticed he hasn’t been passing much urine in the last three days.

On examination, he is breathless at rest with a respiratory rate of 26 breaths/min, oxygen saturations of 88% on air and a few scattered crepitations on auscultation. His heart rate is 95 beats/min, his blood pressure 169/102 mmHg and his capillary refill time is less than three seconds. His heart sounds are normal, there is no significant peripheral oedema and his mucous membranes are moist. His abdomen is soft to palpation and there is no organomegaly. After urinary catheterization only a small amount of urine is passed and the nurse reports it only showed protein and blood. A chest x-ray reveals widespread patchy infiltrates.

Hb 105 g/l
Platelets 490 * 109/l
WBC 8.5 * 109/l
Na+ 139 mmol/l
K+ 5.1 mmol/l
Urea 31.5 mmol/l
Creatinine 894 µmol/l

What is the most appropriate treatment for this patient?