Archives: MRCP Part 2

MRCP2-4035

A 67-year-old man visits the nephrology outpatient department for his yearly review appointment. He has a medical history of stage IIIb chronic kidney disease and hypertension. He takes amlodipine, ramipril, and doxazosin. He is a non-smoker and non-drinker who lives alone and works as a non-executive director for a multinational company.

During his visit, his vital signs are heart rate 84 beats per minute, blood pressure 156/88 mmHg, respiratory rate 16/minute, oxygen saturation 98% on room air, and temperature 36.7ºC. Physical examination reveals a well-looking man who is clinically euvolemic. Cardio-respiratory and abdominal examinations are unremarkable.

The consultant reviews his recent blood tests, which show Hb 124 g/L, platelets 189* 109/L, WBC 9.2 * 109/L, Na+ 137 mmol/L, K+ 4.2 mmol/L, urea 8.9 mmol/L, creatinine 184 µmol/L, CRP 4 mg/L, adjusted calcium 2.01 mmol/L, phosphate 1.81 mmol/L, albumin 38 g/L, ALP 145 IU/L, and parathyroid hormone 7.6 pg/L.

What is the best initial approach to managing his mineral bone disease associated with chronic kidney disease?

MRCP2-4036

John is an 80-year-old man with a history of chronic kidney disease. He comes to the clinic for a routine follow-up of his blood tests. He reports feeling well and denies any significant bone pain or urinary issues. No recent bone fractures were noted.

The blood test results from 1 week ago are as follows:

– Na+ 138 mmol/L (135 – 145)
– K+ 4.8 mmol/L (3.5 – 5.0)
– Urea 8.0 mmol/L (2.0 – 7.0)
– Creatinine 260 µmol/L (55 – 120)
– Calcium 1.8 mmol/L (2.1-2.6)
– Phosphate 2.0 mmol/L (0.8-1.4)
– Magnesium 0.8 mmol/L (0.7-1.0)
– PTH 75 pg/ml (10-55)

Based on these results, what is the most appropriate course of action for managing John’s abnormal blood tests?

MRCP2-4037

A 26-year-old man presents to the clinic with an enlarged testicle. During a self-examination in the shower, he noticed that his left testicle was significantly larger than the right. He reports no specific symptoms, but has experienced a 5kg weight loss over the past 5 months, which he attributed to a new diet. Additionally, he has been feeling fatigued for the past month.

The patient has no significant medical history and is not taking any regular medications. He is sexually active with his partner of 4 years and denies alcohol, smoking, and recreational drug use.

There are no other notable symptoms upon further questioning.

On clinical examination, there are no abnormalities other than an enlarged, non-tender, left testicle. There is no palpable lymphadenopathy or gynaecomastia.

What is the most appropriate next step in the evaluation of this patient?

MRCP2-4038

A 36 year-old man presented to his GP with weakness and arthralgia. He had a past history of liver cirrhosis secondary to hepatitis C virus infection which was contracted 8 years ago, however he had failed to attend any clinic appointments over the past 12 months.

On examination, his pulse was 85 beats per minute and his blood pressure was 140/80 mmHg. There was a purpuric rash affecting his lower limbs. Urinalysis showed blood 2+ and protein 2+.

Hb 128 g/l
Platelets 577 * 109/l
WBC 10.9 * 109/l

Na+ 137 mmol/l
K+ 4.1 mmol/l
Urea 7.3 mmol/l
Creatinine 186 µmol/l

What investigation is most crucial for diagnosis?

MRCP2-4039

A 57-year-old male presents with oliguria, fever and proteinuria nine days after renal transplant. Upon examination, his abdomen is soft and non-tender, and the transplant scar has a mild serous ooze but is otherwise clean. A urine dip reveals protein 4+ blood 1+, and his urine output over the past 3 hours has been 27, 20 and 12 ml/hour respectively. His blood tests from 24 hours ago show:

– Hb: 99 (98) g/dl
– Platelets: 190 (185) * 109/l
– WBC: 3.6 (3.6) * 109/l
– Na+: 139 (136) mmol/l
– K+: 4.9 (4.6) mmol/l
– Urea: 19 (7.8) mmol/l
– Creatinine: 225 (117) µmol/l

A renal ultrasound shows a normal-sized transplanted kidney with no ureteric leak or hydronephrosis. His tacrolimus levels are within the normal range. An urgent renal biopsy of the transplanted kidney reveals significant lymphocytic, particularly mononuclear cell infiltration with no clonal populations, EBV antigen negative, and no light chains. His CMV titre is negative, and his tacrolimus level is therapeutic. What is the most appropriate immediate management?

MRCP2-4041

An 80-year-old man presented to his GP complaining of gradual bilateral lower limb swelling over the past month. He also reported experiencing back pain and widespread joint pains. Upon examination, the patient was found to have macroglossia, a pulse of 90 beats per minute, and a blood pressure of 160/95 mmHg. Urinalysis revealed 4+ protein and 1+ blood. Blood tests showed abnormal levels of Hb, creatinine, bicarbonate, and albumin, among others. The patient was referred to a nephrologist who conducted a renal biopsy, which revealed nodular glomerulosclerosis with amorphous hyaline deposits in the glomeruli. Congo red stain was positive. What is the most likely underlying disorder?

MRCP2-4042

A 65-year-old male with stable congestive heart failure presents to the clinic. He is currently taking furosemide 80 mg once daily, digoxin 125 mcg once daily, enalapril 20 mg once daily, and ibuprofen 600 mg three times daily (taken for the last month). During his last visit three months ago, his renal function was normal, and his furosemide dose was increased from 40 mg to 80 mg per day. His baseline blood pressure is 125/75, and his current blood pressure is measured at 120/70 mmHg. Upon investigation, his serum sodium is 132 mmol/L (137-144), serum potassium is 5.4 mmol/L (3.5-4.9), serum urea is 18 mmol/L (2.5-7.5), and serum creatinine is 270 µmol/L (60-110). What is the most likely cause of the deterioration in his renal function?

MRCP2-4043

A 42-year-old man presents to the acute medical unit with a one-day history of rash and fever. He has a medical history of hypertension and osteoarthritis and takes amlodipine and naproxen as needed. He denies smoking or drinking alcohol.

His vital signs are heart rate 92 beats per minute, blood pressure 143/88 mmHg, respiratory rate 18/minute, oxygen saturations 97% on room air, and temperature 37.7ºC.

Upon examination, there is a mild blanching macular erythematous rash on his trunk. Chest auscultation is normal, and there is no meningism. Heart sounds are normal with no added sounds or murmurs. Neurological examination is unremarkable, and he appears euvolemic.

Urinalysis showed leucocytes +++, nitrites -ve, blood -ve, protein +, and glucose -ve. Blood tests reveal Hb 138 g/L, platelets 189 * 109/L, WBC 10.9 * 109/L, Neuts 6.8 * 109/L, Lymphs 3.1 * 109/L, Mono 0.2 * 109/L, Eosin 0.8 * 109/L, Na+ 137 mmol/L, K+ 4.1 mmol/L, Bicarbonate 21 mmol/L, Urea 9.2 mmol/L, Creatinine 155 µmol/L, and CRP 4g/L.

What is the most likely diagnosis?

MRCP2-4044

A 50-year-old man comes to the nephrology clinic for a routine follow-up after receiving a renal transplant three months ago. He has a medical history of hypertension and takes tacrolimus, prednisolone, amlodipine, ramipril, spironolactone, and doxazosin. He does not smoke or drink alcohol. On examination, there are no notable findings, and there is no tenderness over the transplanted kidney.

Blood tests taken a month ago showed a urea level of 5.2 mmol/L (2.0 – 7.0) and a creatinine level of 88 µmol/L (55 – 120). However, current blood tests reveal a urea level of 14.2 mmol/L (2.0 – 7.0) and a creatinine level of 189 µmol/L (55 – 120). Urinalysis shows protein ++, leucocytes +++, and no blood or nitrites. Glucose is also negative.

What is the probable diagnosis?

MRCP2-4045

A patient in their mid-50s presents to the MAU with worsening dyspnoea. They have a past medical history significant for chronic hepatitis B, which is regularly monitored but currently untreated. Upon further examination, there is widespread oedema with peripheral oedema extending to involve the scrotum and abdominal wall.

Urinalysis
Blood –
Protein +++
Glucose +
White cells –

Blood results:

Hb 9.8 g/dl
Platelets 540 * 109/l
WBC 10.2 * 109/l
ESR 72 mm/hr

Na+ 133 mmol/l
K+ 4.8 mmol/l
Urea 18.9 mmol/l
Creatinine 220 µmol/l
CRP 6 mg/l

Chest X-Ray Normal

What is the most likely diagnosis?