Archives: MRCP Part 2

MRCP2-4076

A 55 year-old man presents with right flank pain. The pain is 9/10 on the pain scale, and does not radiate anywhere. He has also suffered from thirst, polyuria and fatigue, which he has put down to stress from being off work due to a history of chronic lumbar back pain. He has a smoking history of 10 pack years and drinks on average a couple of pints of beer at the weekends. He has no relevant family history.

On examination, he has tenderness in the right flank and lower back and his blood pressure is 149/92 mmHg. Blood tests reveal Hb 9.9 g/dL, platelets 284 * 109/l, WBC 10.5 * 109/l, mean corpuscular volume 86 fl, Na+ 129 mmol/l, K+ 3.9 mmol/l, urea 16.3 mmol/l, creatinine 410 µmol/l, calcium 2.19 mmol/l, phosphate 1.79 mmol/l, and uric acid 0.40 mmol/l.

Urinalysis reveals protein ++, leucocytes +. Microscopy reveals renal papillary cells and casts. No organisms are identified. A plain abdominal x-ray is negative for calculi and calcification. Intravenous urogram reveals clubbed calyces and ring signs.

What is the most likely diagnosis?

MRCP2-4080

A 68-year-old man presents to the General Medical Clinic with a 3-week history of polyuria, polydipsia, and muscle weakness. He reports no weight loss but does experience deep aching pains in his arms, legs, and lower back. His medical history includes hypertension treated with amlodipine and ramipril, as well as an antibody disorder requiring yearly follow-up at the Haematology Clinic. On examination, he appears well with a pulse of 74 bpm and blood pressure of 132/63mmHg. A series of investigations are ordered, including a urine dip that reveals glucose and protein. Based on these findings, what is the most likely diagnosis?

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?

MRCP2-4075

A 38-year-old patient presents to the Emergency Department with worsening swelling of his legs over the past few weeks. He has never had this problem before. He does not feel short of breath and has no chest pain. His past medical history includes asthma, hepatitis C and depression.

The patient appears to have sunken cheeks and a number of depressions in his skin across his upper arms and chest. On auscultation his chest is clear, heart sounds I+II are present and there are no added sounds. His abdomen is soft and non-tender. He has pitting oedema to the knees bilaterally.

Observations are as follows: temperature 36.3ºC, blood pressure 179/111 mmHg, heart rate 89/min, respiratory rate 16/min, saturations 97% on air

Initial investigations are as follows:

Hb 120 g/l
Platelets 170 * 109/l
WBC 9.2 * 109/l
Neuts 4.0 * 109/l
Na+ 144 mmol/l
K+ 4.9 mmol/l
Urea 12.6 mmol/l
Creatinine 166 µmol/l
Adjusted calcium 2.35 mmol/l
Albumin 26 g/l

Urine: blood ++, nitrites -ve, leucocytes -ve, protein +++

What is the most likely underlying diagnosis for this 38-year-old patient?

MRCP2-4078

A 42-year-old Indian man is seen in the renal outpatient clinic. He has been experiencing a gradual decline in his renal function for the past 4 years due to poorly controlled type 2 diabetes mellitus. His eGFR is currently at 8 ml/min, but he is still able to pass urine. Recent ultrasound scans have indicated that he is a suitable candidate for a renal transplant. However, given his ethnicity, there is an uncertain wait for organ suitability should he choose to pursue this option. During the consultation, his 17-year-old daughter offers to donate a kidney due to the high likelihood of compatibility, which the patient is interested in exploring.

The patient’s blood test results are as follows:

Hb 92 g/l
Platelets 180 * 109/l
WBC 7.0 * 109/l

Na+ 142 mmol/l
K+ 5.5 mmol/l
Urea 19.8 mmol/l
Creatinine 290 µmol/l
pH 7.30

What would be the most appropriate course of action at this point?

MRCP2-4072

A 23-year-old female presents to the hospital with complaints of abdominal pain, loose stools, wrist and ankle pain, and a sore throat three days prior. Upon examination, a non-blanching maculopapular rash is observed on her back, buttocks, and lower legs, and her blood pressure is elevated at 175/90 mmHg. Laboratory investigations reveal elevated serum urea and creatinine levels, decreased serum albumin levels, and protein and blood in her urine. What would be the most appropriate initial treatment for this patient?

MRCP2-4073

A 39-year-old known ulcerative colitis (UC) patient presents to the emergency department with sudden onset severe pain in the left loin to groin area. The patient has no other medical issues and had a panproctocolectomy and ileostomy 4 years ago after a colitis flare that did not respond to medical treatment. During the examination, the patient is visibly in pain, and the urine dip shows 3+ RBCs. The patient is given diclofenac and 5 mg IV morphine, which helps alleviate the pain. After the patient is pain-free, their vital signs are normal.

The blood tests reveal:

– Hb 145 g/l
– Platelets 455 * 109/l
– WBC 11.9 * 109/l
– Na+ 136 mmol/l
– K+ 4.5 mmol/l
– Urea 8.8 mmol/l
– Creatinine 99 µmol/l
– Calcium (adj) 2.48 mmol/L
– CRP <10 mg/L A KUB X-ray is performed, which shows a stone in the ureter on the left side. What type of renal stone is likely causing the patient’s symptoms?

MRCP2-4074

A 43-year-old woman with known systemic lupus erythematosus presents with a 3-month history of fatigue, bilateral leg swelling and increasing abdominal distension. On examination, she had periorbital oedema, ascites and pitting oedema to the groin. Her chest was clear, the heart sounds were normal and her jugular venous pressure was not raised. Investigations reveal abnormal results for haemoglobin, white cell count, platelets, mean corpuscular volume, albumin, sodium, potassium, bilirubin, urea, alkaline phosphatase, creatinine, aspartate transaminase, cholesterol, urinalysis and 24-hour urinary protein excretion. She was commenced on treatment with high-dose diuretics and immunosuppressant therapy. Several weeks later, she was readmitted with abdominal pain. On examination, she had mild pyrexia and was tender in both loins. Repeat investigation reveals abnormal results for haemoglobin, white cell count, creatinine, sodium, potassium, urea, urinalysis and blood. What is the most likely cause for the acute deterioration in renal function?

MRCP2-4081

A 35-year-old construction worker presents for review. He visited the doctor complaining of fatigue and weakness, abdominal discomfort and migraines. He works regularly on building sites.
Only medical history of note includes lisinopril for hypertension and occasional joint pain, which has become a recent problem over the past few months.
On examination, his blood pressure is 140/90 mmHg, with pulse 80 and regular. He appears pale and has a peripheral neuropathy.
Investigations:
s
Haemoglobin (Hb) 95 g/l (hypochromic, microcytic anaemia) 135 – 175 g/l
White cell count (WCC) 8.5 × 109/l 4.0 – 11.0 × 109/l
Platelets (PLT) 200 × 109/l 150 – 400 × 109/l
Sodium (Na+) 136 mmol/l 135 – 145 mmol/l
Potassium (K+) 3.6 mmol/l 3.5 – 5.0 mmol/l
Creatinine (Cr) 118 μmol/l 50 – 120 μmol/l
Uric acid 620 µmol/l

What is the most likely diagnosis based on this clinical presentation?

MRCP2-4077

A 32-year-old man presents to the hospital with a 4-day history of feeling generally unwell, experiencing fatigue, joint pain, and itching. He had recently completed a 7-day course of antibiotics for a respiratory infection but has no significant medical history. On clinical examination, he has a widespread red rash. The following investigations were conducted:
Haemoglobin (Hb): 130 g/l (normal range: 130-170 g/l)
White cell count (WCC): 12.5 × 109/l (with eosinophilia) (normal range: 4.0-11.0 × 109/l)
Platelets (PLT): 380 × 109/l (normal range: 150-400 × 109/l)
Creatinine (Cr): 710 μmol/l (normal range: 60-110 μmol/l)
Sodium (Na+): 138 mmol/l (normal range: 135-145 mmol/l)
Potassium (K+): 5.0 mmol/l (normal range: 3.5-5.0 mmol/l)
Urea: 20.0 mmol/l (normal range: 2.5-6.5 mmol/l)
Urinalysis: Protein ++, blood +
What is the most crucial investigation to establish the diagnosis?