Archives: MRCP Part 2

MRCP2-4049

A 35 year old male presents with sudden onset, sharp, right sided chest pain and a 5 month history of increasing leg swelling, weight gain and abdominal distension. He has no past medical history of note. On examination he is tachycardic at 105/min with otherwise normal observations. Cardiovascular and respiratory examinations are normal; there is shifting dullness on examination of the abdomen with no masses palpable. There is also bilateral pitting oedema to the groins. Electrocardiogram shows sinus tachycardia. Urine dip shows 3+ protein nil else. Chest X-ray is unremarkable. Blood tests show the following:

Hb 137 g/l Na+ 141 mmol/l Bilirubin 12 µmol/l
Platelets 275 * 109/l K+ 4.4 mmol/l ALP 89 u/l
WBC 9.2 * 109/l Urea 4.3 mmol/l ALT 33 u/l
Neuts 7.3 * 109/l Creatinine 86 µmol/l γGT 47 u/l
Lymphs 1.4 * 109/l Albumin 20 g/l

What is the most likely cause of his chest pain?

MRCP2-4046

A 35-year-old woman is referred by her primary care physician to the emergency department with sudden and severe right-sided flank pain. She has no history of cardiovascular or kidney disease. On examination, her BMI is 28 kg/m2 and pulse is 82 bpm and regular. Her jugular venous pressure is normal, heart sounds are regular, and her chest is clear. She has a mass in her right flank.
Investigations reveal the following:
Sodium (Na+) 140 mmol/l 135–145 mmol/l
Potassium (K+) 4.2 mmol/l 3.5–5.0 mmol/l
Urea 10.2 mmol/l 2.5–6.5 mmol/l
Creatinine 203 µmol/l 50–120 µmol/l
Haemoglobin (Hb) 150 g/l 135–175 g/l
White cell count (WCC) 5.1 × 109/l 4.0–11.0 × 109/l
Mean corpuscular volume (MCV) 81 fl 80–100 fl
Platelets (PLT) 243 × 109 /l 150–400 × 109/l
Erythrocyte sedimentation rate (ESR) 8 mm/hour 1–20 mm/hour
Urine dipstick blood +++, protein +
What other condition is this patient most likely to be suffering from?

MRCP2-4048

A 20-year-old man arrives at the Emergency Department complaining of severe left flank pain that is radiating to his groin. He reports having experienced this pain before and attributes it to kidney stones. His medical records indicate that he has been admitted three times previously for ureteric calculi, with the most recent episode requiring ureteric stents and lithotripsy. He does not take any regular medications but drinks 3 liters of water per day as advised by his urologists.

During the examination, the patient appears restless and is pacing. He has a normal body temperature, a pulse rate of 93 bpm, and a blood pressure of 148/79 mmHg. His abdomen is soft, but there is tenderness over the left costovertebral angle upon percussion. A plain abdominal film reveals a semi-opaque, left proximal ureteral stone with a ‘ground glass’ appearance.

The patient’s 24-hour urine results are as follows:
– Calcium 3.1 mmol/day (2.5 – 7.5)
– Oxalate 0.28 mmol/day (0.11 – 0.46)
– Phosphate 17.4mmol/day (15 – 20)
– Urate 1.8 mmol/day (1.5 – 4.5)
– Cystine 1.9mmol/day (<0.13)
– pH 7.5

What is the most appropriate treatment for this likely diagnosis?

MRCP2-4034

A 40-year-old man presents to renal clinic for a follow-up appointment. He has been under surveillance for autosomal dominant polycystic kidney disease for the past 8 years. The patient is currently asymptomatic but worried about the ongoing decline in his renal function as monitored by his general practitioner. He has no significant medical history and is not allergic to any medications. The patient is taking ramipril 5 mg daily.

During the clinical examination, bilateral palpable kidneys with a euvolaemic fluid status were noted. The patient’s blood pressure in clinic was 110/75 mmHg. The following are the serial renal function and ultrasound results over the period of follow-up:

Date Estimated glomerular filtration rate mL/min/1.73 m3
8 years previous 68
5 years previous 62
2 years previous 59
Present 41

Date Increase in total kidney volume relative to previous measurement
8 years previous +2%
5 years previous +2%
2 years previous +7%
Present +12%

What is the appropriate management plan to slow down the rate of decline in the patient’s renal function?

MRCP2-4050

A 65-year-old male Jehovah’s witness presents to the hospital with increasing fatigue and malaise over the past 4 weeks. He has been bedridden for the past day. The patient has a medical history of stage 5 chronic kidney disease, hypertension, and type 2 diabetes. Despite his kidney disease, he is still able to pass urine without renal replacement therapy, with a baseline creatinine of 260 µmol/l. Upon examination, he appears warm peripherally with conjunctival pallor. His heart sounds are normal, his chest is clear, and his abdomen is soft and non-tender. He has passed 800mls of urine in the last 24 hours. The following are his blood test results:

Hb 80 g/l
Platelets 201 * 109/l
WBC 6.7 * 109/l
Ferritin 4 ng/ml
Transferrin saturation 19%

Na+ 145 mmol/l
K+ 4.9 mmol/l
Urea 17.7 mmol/l
Creatinine 276 µmol/l

What is the most appropriate course of action?

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?

MRCP2-4045

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?

MRCP2-4032

An 80 year-old man visited his GP complaining of swelling in his lower limbs that had developed over the past week. He also reported having frothy urine. The patient had a history of lung cancer and was about to start palliative chemotherapy. On examination, his blood pressure was 150/90 mmHg and his pulse was 88 beats per minute. Urinalysis showed 4+ protein and 1+ blood. The patient’s lab results revealed a hemoglobin level of 110 g/l, platelets of 375 * 109/l, and a WBC count of 4.9 * 109/l. His sodium level was 136 mmol/l, potassium was 4.6 mmol/l, urea was 23.0 mmol/l, creatinine was 420 µmol/l, serum albumin was 18 g/L, and his 24-hour urine protein was 4.5 g (<0.2). What is the most likely diagnosis?

MRCP2-4033

A 75-year-old man with chronic kidney disease, who has been on haemodialysis for more than a decade, is experiencing difficulty with elevated serum phosphate levels despite claiming adherence to phosphate binders. He has been referred to consult with the renal dietician and his weekly dietary intake is being evaluated. What food or beverage is most likely to be responsible for his high phosphate levels?

MRCP2-4020

A 40-year-old man with type 1 diabetes has visited his doctor for his annual check-up. During the examination, his blood pressure is found to be high at 163/72 mmHg. His blood test results reveal a sodium level of 137 mmol/L (137-144), potassium level of 4.2 mmol/L (3.5-4.9), urea level of 9.5 mmol/L (2.5-7.5), and creatinine level of 125 μmol/L (60-110) with an estimated glomerular filtration rate (eGFR) of 58 ml/min/1.73m2. The doctor is concerned about the possibility of diabetic nephropathy leading to chronic kidney disease and wants to accurately measure the patient’s proteinuria. What is the most suitable test to suggest in this scenario?