Archives: MRCP Part 2

MRCP2-4022

A 57-year-old man presents to the hospital with lower abdominal pain. He has a medical history of Parkinson’s disease, psoriasis, and high cholesterol. His current medications include methotrexate 10 mg once weekly, bromocriptine 2.5mg BD, atorvastatin 20mg ON, levodopa 200 mg TDS, and entacapone 200 mg OD. Upon admission, his vital signs are heart rate 102 beats per minute, blood pressure 125/62 mmHg, respiratory rate 18/min, oxygen saturations 97% (room air), and temperature 37.2ºC. On examination, he has bilateral loin tenderness with no evidence of peritonism, and bowel sounds are active. A urine dipstick confirms blood 2+ with no evidence of nitrites or leukocytes. An abdominal x-ray is unremarkable. Which medication is likely to be associated with the underlying diagnosis?

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?

MRCP2-4024

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?

MRCP2-4025

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?

MRCP2-4026

A 31-year-old man presented to his GP with complaints of persistent headaches and nasal congestion for the past 4 weeks. Despite taking over-the-counter decongestants and flu remedies, his symptoms did not improve. He also experienced recurrent nosebleeds and coughed up fresh blood a few times. Additionally, he had been having night sweats. The patient had no prior medical history and was not taking any regular medications.

The GP was concerned about the patient’s symptoms and ordered some blood tests. The results showed a low haemoglobin level, high potassium level, and elevated creatinine level. The GP admitted the patient to the hospital to investigate the cause of the high creatinine level. Further tests revealed protein and blood in the urine, as well as multiple, well-defined lesions in both lung fields on a chest X-ray. The patient tested positive for c-ANCA with high PR3 titres and negative for p-ANCA and Anti-GBM antibodies. Complement levels were normal.

Based on the patient’s presentation, what type of glomerulonephritis (GN) would be expected on a renal biopsy?

MRCP2-4027

An 80-year-old man is admitted to the hospital with worsening productive cough, fever, and difficulty breathing. He appears confused and dehydrated, with increasing muscle pain. His vital signs show a temperature of 37.7ºC, a heart rate of 102/min, and a blood pressure of 95/65 mmHg. He is currently taking bisoprolol 2.5 mg OD, aspirin 75 mg OD, simvastatin 40 mg OD, ramipril 3.75 mg OD, amlodipine 5 mg OD, and allopurinol 300 mg OD. His wife reports that his GP recently prescribed a new medication for his cough.

The patient’s blood work shows a hemoglobin level of 104 g/l, platelets at 525 * 109/l, WBC at 16.5 * 109/l, and lymphocytes at 3.2 * 109/l. His sodium level is 131 mmol/l, potassium level is 6.2 mmol/l, and urea level is 21.1 mmol/l. His creatinine level is 365 µmol/l, CRP level is 79 mg/l, and creatinine kinase level is 1325 u/l.

Which recently prescribed medication could explain the abnormal blood picture in this patient?

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?

MRCP2-4029

A 87-year-old woman is admitted to the orthopaedic ward after falling and lying on the floor for four hours. She was brought in by ambulance and diagnosed with a left intertrochanteric fractured neck of femur. She underwent surgery eight hours later and had fixation with a dynamic hip screw. During surgery, she received three units of blood.

The following day, the orthogeriatric team assessed her. In the last 24 hours, she has passed 300ml of urine. Her creatinine level from the previous day was 170 umol/l, and her baseline creatinine from three months ago was 50 umol/l. She weighs 60kg.

What is the most appropriate way to describe her current kidney function?

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?

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?