Archives: MRCP Part 2

MRCP2-4028

A 55-year-old woman presents to the emergency department with pain radiating from her left loin to her left groin. She has a past medical history of recurrent urinary tract infections and is on prophylactic nitrofurantoin. There are no similar previous episodes and there is no history of renal tubular acidosis.

Observations:

Heart rate 98 beats per minute
Blood pressure 130/75 mmHg
Respiratory rate 16/minute
Oxygen saturations 97% on room air
Temperature 37.2C

On examination, the patient is restless and in pain. There is no peritonism.

Urinalysis:

Blood +++ (negative)
Protein negative (negative)
Leucocytes + (negative)
Glucose negative (negative)
pH 8.5 (4-8)

What is the probable diagnosis and what is the likely composition of causative pathology?

MRCP2-4019

A 56-year-old-man with a history of granulomatosis with polyangiitis presents for his annual review in the rheumatology clinic. He was diagnosed at age 37 where he presented with rapidly progressive glomerulonephritis and pulmonary haemorrhage and was treated with cyclophosphamide and steroids. He required a period of haemofiltration on the intensive care unit but has remained well since.

Today, he reports occasional blood in his urine but feels well after recently quitting smoking. On examination, his abdomen is soft and non-tender, there is no pallor or oedema, and his chest is clear. His investigations are below, and his urine appears clear.

Hb 105 g/l
Platelets 300* 109/l
WBC 5* 109/l
Urinalysis blood 3+ protein –
Na+ 139 mmol/l
K+ 4.2 mmol/l
Urea 5.6 mmol/l
Creatinine 98 µmol/l

What is the likely diagnosis for this patient?

MRCP2-4025

A 20-year-old college student presents to the Emergency Department with a decreased consciousness level. His roommate reports that he has been struggling with living away from home recently and has been isolating himself from his friends. Several of his friends have recently experienced a self-limiting episode of vomiting and diarrhea. Upon admission, the patient is tachycardic, tachypneic, hypotensive, and hyperglycemic.

What is the underlying cause of the hyperchloremic metabolic acidosis in this 20-year-old patient?

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?

MRCP2-4021

A 68-year-old woman presents with a cough and fever. She has been feeling unwell for four days with a worsening productive cough, chest pain, fever, and shortness of breath. Upon observation, she shows tachycardia, fever, and hypoxia. Her weight is 42kg. A chest x-ray reveals right middle lobe consolidation, and she is diagnosed with sepsis and a lower respiratory tract infection.

The patient is administered IV fluids, IV antibiotics, and a urinary catheter is inserted. During the post-take ward round, which is 8 hours later, it is noted that she has passed 141 ml of urine, which appears dark. Upon calculation, it is determined that she is passing urine at a rate of 0.42ml/kg/hr. Her creatinine level upon admission is 87µmol/L, and there are no previous records of creatinine levels.

What is the most appropriate way to describe her renal function?

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?

MRCP2-4024

A 65-year-old man is seen in an outpatient renal clinic. He has a history of hypertension and has been diagnosed with type 2 diabetes mellitus for the past 10 years. His eGFR is 20mls/min/1.73m², and it is expected that he will require renal replacement therapy within the next two years.

The patient is currently taking the following medications: Atorvastatin 20 mg nocte, lisinopril 10mg daily, amlodipine 5mg daily, ferrous sulphate 200mg daily, and a basal bolus regimen of insulin. He had previously been taking alfacalcidol and calcium acetate, but they were recently discontinued.

During the examination, the patient presents with some pitting ankle edema up to his mid-tibia, a few bibasal crepitations on examination of his chest, and appears comfortable at rest. There are no signs of uraemia.

The following are the results of the patient’s investigations:

– Sodium: 140 mmol/L
– Potassium: 4.8 mmol/L
– Serum corrected calcium: 2.55 mmol/L
– Serum phosphate: 2.1 mmol/L
– Plasma parathyroid hormone concentration: 3.5 pmol/L (0.9-5.4)

What would be the most appropriate course of action to correct the patient’s phosphate concentration?

MRCP2-4031

A 47-year-old woman has been hospitalized for the last 12 days to treat bronchopneumonia. She has recently experienced chills, fever, and a skin rash over the past 48 hours. A peripheral blood film shows eosinophilia, and her urinalysis indicates ++ proteinuria. She has no prior history of renal disease, and her HbA1c is within normal range. Based on these results, what diagnosis is most likely?

MRCP2-4023

A 45-year-old man presents to the emergency department with abdominal pain and fever. He has a past medical history of end-stage renal failure secondary to type 1 diabetes. His method of renal replacement therapy is peritoneal dialysis. His medications include insulin and atorvastatin. He does not smoke or drink alcohol.

Observations:

Heart rate 101 beats per minute
Blood pressure 120/73 mmHg
Respiratory rate 18/minute
Oxygen saturations 96% on room air
Temperature 38.4°C

Upon examination, there is mild abdominal tenderness. Bowel sounds are present. The dialysate fluid appears cloudy.

What is the appropriate antibiotic choice for the likely diagnosis?

MRCP2-4030

You are presented with a 43-year-old female patient who has been admitted with dehydration and a history of borderline personality disorder, alcohol excess, and three previous upper gastrointestinal bleeds requiring endoscopic intervention. She is currently taking lithium MR 400 mg once daily, omeprazole 40 mg once daily, and thiamine 100 mg twice daily. Upon admission, her renal function and osmolalities were as follows: Na 155 mmol/L, K 4.9 mmol/L, urea 13.0 mmol/L, and creatinine 251 µmol/L. Her plasma osmolality was 329 mmol/kg (275-295 mmol/kg), and urine osmolality was 56 mmol/kg (500-800 mmol/kg). Despite receiving 5% glucose infusions, her renal function has not improved significantly. A water deprivation test with desmopressin was performed, and the pre- and post-desmopressin urine osmolalities were 64 mmol/kg and 72 mmol/kg, respectively. What is the most appropriate treatment for this patient’s likely diagnosis?