Archives: MRCP Part 2

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?

MRCP2-4087

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?

MRCP2-4089

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?

MRCP2-4090

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:

Hb 12.7 g/dl
Platelets 80 * 109/l
WBC 17.1 * 109/l

Na+ 141 mmol/l
K+ 3.5 mmol/l
Creatinine 77 µmol/l
CRP 99 mg/l
PSA 6 ng/dl

What is the recommended treatment course for this likely diagnosis?

MRCP2-4091

As the medical registrar on-call, you receive a patient in the ED who is a 75-year-old male with clinical findings consistent with critical limb ischaemia. The patient has a medical history of diabetes and chronic kidney disease (Stage 4). The vascular surgeons admit the patient and request a CT angiogram. They provide you with the following blood results:

Today 1 month ago
Na+ 141 mmol/l 138 mmol/l
K+ 4.7 mmol/l 4.4 mmol/l
Urea 15.8 mmol/l 9.8 mmol/l
Creatinine 241 µmol/l 158 µmol/l

What evidence-based recommendations would you provide to minimize the risk of contrast-induced nephropathy?

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?

MRCP2-4093

A 35-year-old woman who is 20 weeks’ pregnant with her second pregnancy presents for a routine antenatal check. She has a history of two hospital admissions for pyelonephritis during childhood but takes no regular medication. On examination, her blood pressure is 140/90 mmHg. It is rechecked an hour later and found to be 136/88 mmHg. No other significant abnormalities are found. The following investigations are performed:

Investigation Result Normal value
Sodium (Na+) 138 mmol/l 135-145 mmol/l
Potassium (K+) 4.0 mmol/l 3.5-5.0 mmol/l
Urea 4.2 mmol/l 2.5-6.5 mmol/l
Creatinine 130 µmol/l 50-120 µmol/l
Urinalysis NAD
Ultrasound scan, kidneys:
Right kidney BPD 11.2 cm
Left kidney BPD 6.0 cm
Left kidney Irregular outline

What is the most likely diagnosis?

MRCP2-4068

A 70 year old man was brought to the Emergency Department after collapsing at home. He had been feeling unwell for five days with frequent diarrhea and vomiting. His wife reported that he had not been able to keep down any fluids for the past two days. There was no history of recent travel. Past medical history included a prostatectomy at age 60 years for benign prostatic hyperplasia. The patient takes no regular medications.

The initial assessment of the patient documented in the Emergency Department is as follows.

Airway: patient’s own

Breathing: respiration shallow but no overt respiratory distress; respiratory rate 22 / min; oxygen saturations 98 % (15 L O2); chest clear and resonant; trachea central

Circulation: dry mucous membranes; capillary refill time 6 seconds; blood pressure 80/40 mmHg; heart rate 120 / minute regular

Disability: GCS 14; temperature 36.5 Celsius, pupils equal and reactive to light; spontaneous movements of all limbs; plantars downgoing bilaterally

Exposure: abdomen soft and generally mildly tender; nil other abnormality

Results from an arterial blood sample (15 L O2) were as follows.

pH 7.32
PaCO2 36 mmHg (reference 32-43)
PaO2 95 mmHg (reference 70-100)
Bicarbonate 12.0 mmol / L (reference 20.0-26.0)
Sodium 135 mmol / L
Potassium 3.8 mmol / L
Calcium 2.20 mmol / L (reference 2.20-2.60)
Chloride 100 mmol / L (reference 99-108)
Haemoglobin 14.0 g / dL
Lactate 4.5 mmol / L

After initial assessment, IV access was secured and a 500 mL bolus of 0.9 % saline was given. Repeat observation after initial fluid showed BP 85/45 mmHg with heart rate 110 / minute. The patient remained alert.

What is the most appropriate next fluid prescription for this patient?

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?