Archives: MRCP Part 2

MRCP2-4059

A 68-year-old man presents to the Emergency department with shortness of breath. He has a medical history of end stage renal failure secondary to hypertension and renovascular disease.
He is currently receiving haemodialysis as renal replacement therapy and it has been three days since he last dialysed.

On examination, he is tachypnoeic, his jugular venous pressure can be seen 1 cm above the clavicle and there are sparse fine crepitations at the lung bases.

An arterial blood gas on air reveals:
pH 7.32 (7.36-7.44)
pO2 11.9 kPa (11.3-12.6)
pCO2 2.9 kPa (4.7-6.0 kPa)
Bicarbonate 12 mmol/L (20-28)
Sodium 136 mmol/L (137-144)
Potassium 7.5 mmol/L (3.5-4.9)

An ECG reveals first degree heart block and peaked T waves.

What is the most appropriate initial management of this patient’s hyperkalaemia?

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?

MRCP2-4063

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?

MRCP2-4057

A 50 year old woman presents to her General Practitioner with a complaint of polyuria lasting for the past three months. She reports needing to urinate every 60 to 90 minutes during the day and being woken up at least twice at night. She denies any increased urinary urgency or dysuria. The patient has not made any changes to her fluid intake and consumes minimal caffeine and alcohol. She has also experienced loose stools and a weight loss of 4 Kg over recent weeks.

The patient has no significant medical history except for an appendicectomy in childhood and no previous pregnancies. Her twin sister was diagnosed with coeliac disease five years ago. She is not on any regular medications and has no known allergies. On examination, the patient appears slightly anxious and is slim. Cardiovascular, respiratory, and ocular examination is normal, and there are no skin rashes.

Initial investigations requested by the General Practitioner are as follows:

– Haemoglobin: 12.4 g/dL
– White cell count: 6.5 * 109/L
– Platelets: 329 * 109/L
– Urea: 3.5 mmol/L
– Creatinine: 75 micromol/L
– Sodium: 142 mmol/L
– Potassium: 3.7 mmol/L
– Calcium (adjusted): 2.4 mmol/L
– Haemoglobin A1C: 5.3% (reference 4-6)
– Serum glucose (random): 4.7 mmol/L
– Urine dipstick: negative for nitrites, leucocytes, glucose, ketones, protein, and beta-HCG
– Urine microscopy, culture, and sensitivities: white cell count < 10/mm³, no growth What is the most appropriate next test to diagnose the cause of polyuria?

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?

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?

MRCP2-4058

A 55 year-old woman presents to her GP with refractory hypertension despite previous treatment with ramipril, bendroflumethiazide and amlodipine. She has a history of hyperthyroidism which was treated with carbimazole ten years ago, and a 20-year pack history. She drinks 5-10 units of alcohol per week and works in an office. Recently, she has been experiencing pain in both calves when walking to and from work. On examination, her blood pressure is 161/98 mmHg and she has cold peripheries. Blood tests reveal high renin and aldosterone activity, as well as a sodium level of 145 mmol/l, potassium level of 3.3 mmol/l, urea level of 5.1 mmol/l, and creatinine level of 81 µmol/l. What is the most likely diagnosis?

MRCP2-4055

A 38-year-old woman presents for review. She admits to unprotected sex with a number of partners and has suffered a dry cough, shortness of breath and weight loss over the past few months. Her major current complaint is that has had progressive lower limb swelling which has worsened over the past few weeks. Blood pressure on examination is 130/80 mmHg and there is peripheral oedema. Her BMI is 22.

Investigations reveal:
24-h urinary protein excretion 4.8 g
Haemoglobin (Hb) 112 g/l 135–175 g/l
CD4 count 200 cells 500-1500 cells
Albumin 28 g 35–55 g/l
Sodium (Na+) 140 mmol/l 135–145 mmol/l
Potassium (K+) 4.0 mmol/l 3.5–5.0 mmol/l
Creatinine 190 µmol/l 50–120 µmol/l
Urea 11.8 mmol/l 2.5–6.5 mmol/l

What is the initial treatment of choice for this patient’s renal dysfunction?

MRCP2-4062

A 38-year-old male with end-stage renal failure due to IgA nephropathy is admitted to the hospital. He was discharged three days ago after being admitted for hyperkalemia-induced collapse. He is now in the medical assessment unit after experiencing rigors during dialysis earlier today.

After dialysis, his blood tests show:

– White blood cell count: 15.2 *109/l
– Sodium: 134 mmol/l
– Potassium: 2.1 mmol/l
– Urea: 10.6 mmol/l
– Creatinine: 400 µmol/l
– C-reactive protein (CRP): 119 mg/dL

What is the most urgent priority in his management?