Archives: MRCP Part 2

MRCP2-3991

As the endocrinology registrar in the diabetic clinic, you are seeing a 50-year-old female patient with type 2 diabetes mellitus. She is generally in good health and takes only metformin 500 mg bd as her regular medication. She has good hypoglycaemia awareness and rarely experiences hypoglycaemic episodes. Her blood sugar levels range between 5 and 9 on home monitoring.

Routine blood tests reveal the following results: Hb 133 g/l, Plt 141 x10^9/l, WCC 13.4 x10^9/l, Na+ 133 mmol/l, K+ 3.1 mmol/l, urea 3.1 mmol/l, creatinine 33 µmol/l, eGFR 79 ml/kg/1.73m², and HbA1c 46 mmol/mol (6.4%). Urinalysis shows PRO+ and GLUC +, but nothing else. The urinary ACR (albumin:creatinine ratio) is 3.6 mg/mmol.

During the examination, you note that her BMI is 21 kg/m², and she has good peripheral sensation. Her fundi look normal, and her chest is clear to auscultation. Heart sounds are normal with no murmurs, and her abdomen is soft and non-tender. Her heart rate is 72 beats per minute and regular, blood pressure is 124/75 mmHg, respiratory rate is 20/min, oxygen saturations are 98% on air, and temperature is 36.8 degrees.

What medication would you recommend for this patient’s ongoing management?

MRCP2-3982

A 32-year-old woman presents to the Emergency Department with bilateral leg swelling. She takes no regular medications. She reports that at the age of 12, her parents took her to hospital with leg swelling and she was given a short course of steroids which resolved it. She tells you that she has been well and woke up with leg swelling.
On examination, she has bilateral pitting oedema up to her thighs. There are no other clinical findings of note.
Investigations:

Haemoglobin (Hb) 130 g/l 115–155 g/l
White cell count (WCC) 7.5 × 109/l 4.0–11.0 × 109/l
Platelets (PLT) 300 × 109/l 150–400 × 109/l
Creatinine (Cr) 72 µmol/l 50–120 µmol/l
Urea 5.0 mmol/l 2.5–6.5 mmol/l
Albumin 18 g/l 30–50 g/l
Urine protein : creatinine ratio (uPCR) 200 mg/mmol < 5 mg/mmol
Glycated haemoglobin (HbA1c) 5.0% 4.0–6.5%
A kidney biopsy is performed and she is initiated on a course of steroids; her oedema completely resolves within three weeks.
What is the most likely outcome of histology expected on light microscopy if performed?

MRCP2-3985

An 80-year-old man with diabetes has been undergoing regular haemodialysis (four hours three times a week) for the past ten years. He has reported experiencing more frequent muscular aches, numbness, and joint stiffness in his hands, arms, and shoulders. However, his lower limbs remain unaffected. His current medications include calcium carbonate (two tablets three times a day with meals), an ACE inhibitor, aspirin, and 1-alpha calcidol (1 mcg once a day). What could be causing his symptoms?

MRCP2-3986

A 76-year-old Afro-Caribbean woman is worried about the health of her kidneys and requests screening for chronic kidney disease. As per the guidelines of the National Institute for Health and Care Excellence (NICE) on the detection and treatment of chronic kidney disease, which of the following factors is a risk factor and warrants screening for chronic kidney disease?

MRCP2-3994

A 70-year-old man was referred to the medical admissions unit by his GP. He had a 2 month history of lethargy, weight loss and night sweats. He also complained of nasal crusting and shortness of breath with one episode of haemoptysis that morning. He had a past medical history of hypertension, for which he was taking amlodipine.

On examination his blood pressure was 156/94 mmHg and he appeared unwell. There was a petechial rash on both lower limbs.

A chest x-ray was performed which showed bilateral alveolar infiltrates. Blood tests are shown below:

Hb 96 g/L Male: (135-180)
Female: (115 – 160)
Platelets 487 * 109/L (150 – 400)
WBC 15.8 * 109/L (4.0 – 11.0)
Na+ 138 mmol/L (135 – 145)
K+ 5.1 mmol/L (3.5 – 5.0)
Urea 11.2 mmol/L (2.0 – 7.0)
Creatinine 196 µmol/L (55 – 120)
CRP 285 mg/L (< 5)
c-ANCA positive
anti-GBM antibodies negative

A renal biopsy was performed which showed a necrotising crescentic glomerulonephritis.

What would be the criteria to initiate plasma exchange in this case?

MRCP2-3989

A 68-year-old man with a history of heart failure treated with bisoprolol, ramipril, furosemide and spironolactone presents to the clinic with a complaint of painful gynaecomastia that has become more prominent over the past 6 months since he had a medication change. Although his heart failure symptoms are stable, he is concerned about this new development. On examination, his blood pressure is 125/80 mmHg, his pulse is 65 beats per minute and regular. There are only minor basal crackles at both lung bases on auscultation, and minor pitting oedema of both ankles. Routine blood testing is unremarkable including creatinine.

What is the most appropriate management strategy for his gynaecomastia?

MRCP2-3988

A 20-year-old woman presents to the hospital with a suspected overdose of paracetamol that occurred three days ago. She is currently heavily intoxicated with alcohol. Upon admission, her paracetamol levels are undetectable. Although she refuses IV fluids overnight, she agrees to remain in the hospital. The following morning, her blood tests reveal a creatinine level of 180 μmol/L (normal range: 60-110), a bicarbonate level of 26 mmol/L (normal range: 20-28), an ALT level of 53 U/L (normal range: 5-35), an alkaline phosphatase level of 210 U/L (normal range: 45-105), and an INR of 1.1 (normal range: <1.4). Based on these findings, what is the most likely diagnosis?

MRCP2-3996

A 30-year-old man presents to your acute medical unit with right flank pain that has been constant for the past 2 weeks. Despite taking paracetamol tablets, the pain has not subsided. He denies experiencing dysuria and is generally in good health, although he is a smoker. He mentions that his sister recently passed away from a subarachnoid haemorrhage caused by a berry aneurysm.

Upon examination, the patient’s heart rate is elevated at 110 bpm, but all other observations are normal. A urine dipstick test reveals 2+ blood and nothing else. Blood tests show a sodium level of 141 mmol/l, potassium level of 4.6 mmol/l, urea level of 3.6 mmol/l, creatinine level of 84 mol/l, and CRP level of 34 mg/l. His FBC is normal.

What is the most likely diagnosis?

MRCP2-3987

A 47-year-old man with type 2 diabetes mellitus attends a routine diabetes clinic review and is diagnosed with low sodium. Which medication is the most probable cause?

MRCP2-3990

A 40-year-old accountant presents to the general medical clinic with complaints of erectile dysfunction. He has been experiencing difficulty sustaining an erection since starting a new job. Despite being physically fit and having reduced his BMI from 27 to 23 by cycling to work, he has found his new job somewhat stressful. He denies any mental health problems and has no significant medical history apart from an appendectomy at 19 years old. On examination, his genitalia appears normal with normally sized testicles. Blood tests, including testosterone, HbA1c, and routine blood tests, are ordered. What advice should be given to him?