Archives: MRCP Part 2

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?

MRCP2-4081

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?

MRCP2-4080

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?

MRCP2-4076

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?

MRCP2-4063

A 63-year-old man presents to the renal transplant clinic. He underwent a cadaveric kidney transplant a year ago, which was complicated by rejection and required high dose immunosuppression. Despite this, his graft function is good with a creatinine level of 121 umol/l and no proteinuria. He reports a weight loss of 2 stones over the past 2 months and feels fatigued. On examination, a large painless lymph node is found in his right axilla and a palpable node in his left inguinal region. His blood tests show a hemoglobin level of 8.7 g/dl, platelets of 195 * 109/l, and a WBC count of 6.7 * 109/l. What is the most useful virology test to perform?

MRCP2-4061

A 70-year-old man presents to the emergency department following a fall at home. He has been feeling unwell for the past three days with reduced oral intake, nausea, and weakness. He has a history of hypertension and prostate enlargement and is awaiting a TURP in two months. He typically experiences frequency and nocturia but has not passed urine for the last two days. He takes tamsulosin, finasteride, ramipril, and occasional naproxen for joint pains.

Upon examination, the patient appears pale and lethargic. A palpable bladder is noted, and mild crepitations are heard at the bases of his chest. His JVP is raised at 5cm, and his calves are soft and not edematous. His vital signs are heart rate 80/min, temperature 36.9 ºC, respiratory rate 22/min, and blood pressure 140/85 mmHg. A catheter is inserted, and 1400 ml of dark urine is drained.

Lab results show Hb 110 g/l, Na+ 130 mmol/l, platelets 278 * 109/l, K+ 6.0 mmol/l, WBC 11.2 * 109/l, urea 11.3 mmol/l, neuts 9.6 * 109/l, creatinine 493 µmol/l, lymphs 1.0 * 109/l, CRP 23 mg/l, and PSA 5.3 ng/ml (0-2.0 normal range). A urine dip reveals blood +++, leucocytes ++, and nitrites -.

An ultrasound of the catheterized bladder shows no hydronephrosis, and both kidneys are 9.7cm in size. A chest x-ray reveals increased alveolar shadowing in the lower zone and small pleural effusions bilaterally.

What is the probable cause of this acute kidney injury?

MRCP2-4056

A 16-year-old girl presents to the clinic with complaints of muscle weakness, fatigue, and increased urination. During her visit, her blood pressure is measured at 90/74 mmHg. Further investigations reveal abnormal levels of serum sodium, potassium, urea, creatinine, chloride, bicarbonate, and magnesium, as well as elevated levels of urine sodium, potassium, and calcium. Based on these findings, what is the most likely diagnosis for this patient?

MRCP2-4066

A 33-year-old man with a history of sickle cell anemia presents with left-sided loin pain and hematuria for the past three days. The pain is localized and does not radiate to the groin. He has been in good health for several years since his last crisis. He reports recent knee pain related to exercise, which he has been managing with ibuprofen.

During the examination, the patient is tender in the left loin, and a urine sample shows red coloration with visible pieces. There is no jaundice or scleral icterus, but a palpable spleen is felt 2 cm below the costal margin. Further investigations are carried out.

Sodium: 136 mmol/l
Potassium: 4.6 mmol/l
Urea: 5.2 mmol/l
Creatinine: 89µmol/l

Hemoglobin: 96 g/l
Platelets: 178 * 109/l
White blood cells: 9.7* 109/l

Ultrasound of the renal tract reveals a clubbed appearance of calyces and debris in the renal pelvis.

What is the most likely diagnosis?

MRCP2-4064

A 49-year-old male presents to his primary care physician with a 3-month history of worsening swelling in his arms and legs. He has chronic lower back pain and has unintentionally gained 5 kg over the past 2 months. He has a medical history of ankylosing spondylitis, hypertension, and hypercholesterolemia and is currently taking regular paracetamol, amlodipine 5mg OD, and simvastatin 40 mg ON. During the examination, there is pitting edema to his mid-thighs bilaterally, as well as swelling in his face and arms. Respiratory, cardiovascular, and abdominal examinations are normal, and there is a reduction in all spinal movements. The urine dip shows 3+ protein with no other abnormalities, and blood tests reveal a low albumin level and elevated CRP. Based on these findings, what is the most likely cause of this patient’s edema?

MRCP2-4065

A 16-year-old male presents with gradual onset bilateral lower limb and periorbital swelling that started about 3 days ago. He denies any pain or tenderness elsewhere and has no past medical history or drug allergies. He does not take any medications regularly but admits to occasional cigarette and marijuana use for the past 2 years.

Approximately 5 weeks ago, he experienced a few days of cough and cold symptoms, which included swollen glands in his neck, a sore throat, and a temperature of 37.6ºC. He sought medical attention from his GP, who prescribed antibiotics that did not provide much relief. The illness resolved spontaneously after 3 days.

A urine dip reveals 4+ protein with no blood, leucocytes, or nitrites. A 24-hour urine collection demonstrated protein of 3.8g.

Selected blood tests show a urea level of 6.5 mmol/l, creatinine level of 90 µmol/l, normal complement levels, and negative HIV p24 antigen.

His renal biopsy demonstrates podocyte fusion.

What is the likely cause of his presentation?