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?
Archives: MRCP Part 2
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?
MRCP2-3989
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?
MRCP2-3990
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?
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?
MRCP2-3992
A 54-year-old female with progressive proteinuric diabetic nephropathy presents at the renal low clearance clinic. Despite receiving maximal medical therapy, her poorly controlled type 1 diabetes since the age of 20, hypertension, and hypercholesterolemia have led to a deterioration in her kidney function. Although she feels fit and well, she is worried about her condition. Physical examinations reveal a sensory peripheral neuropathy, reduced dorsalis pedis pulses bilaterally, and pitting edema in both ankles. Fundoscopy shows evidence of photocoagulation therapy in both eyes. Blood tests reveal a Hb of 109 g/l, platelets of 111 * 109/l, WBC of 5.7 * 109/l, Neuts of 4.6 * 109/l, HbA1c of 86 mmol/mol, and an eGFR of 18 ml/min/1.732. Her eGFR was 20 three months ago. Given her progressive stage 4 chronic kidney disease, what is the most effective treatment option available?
MRCP2-3993
You are summoned to the renal ward to assess a 44-year-old male patient who has been causing concern among the nursing staff. The man was admitted two weeks ago with acute renal failure, and subsequent blood tests revealed a positive anti-neutrophil cytoplasmic antibody (ANCA) with a myeloperoxidase (MPO) level of 131. A renal biopsy was performed four days after admission, and the provisional pathology report indicated acute crescentic glomerulonephritis (immuno-fluorescence awaited). Five days into his hospital stay, he experienced frank haemoptysis, which was treated with high flow oxygen and did not require transfusion.
You have been called to see him because he collapsed on his way back from the bathroom. He is tachycardic, and his blood pressure is 85/40 mmHg. He looks pale and complains of generalised abdominal pain, but denies any further haemoptysis. Blood tests reveal a white cell count of 12.6 *109/l, haemoglobin of 67 g/l, platelets of 129 *109/l, adjusted calcium of 2.01 mmol/l, prothrombin time of 14 seconds, and fibrinogen of 1.1 g/dL.
An urgent CT angiogram confirms intra-abdominal bleeding at the site of his kidney biopsy.
Which treatment is most likely to have increased his risk of delayed post-biopsy bleed?
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?
MRCP2-3995
A 55-year-old woman, originally from Thailand, presents with a 4 week history of haemoptysis, a dry irritating cough and progressive shortness of breath that has reduced her ability to climb stairs and walk distances greater than roughly 50 meters. She has no other medical history of note apart from an appendectomy when younger. She takes no regular medication except for over the counter herbal remedies that she gets from a local Chinese medicine shop, although she cannot remember what these are called. She smokes 10 cigarettes per day and does not drink alcohol.
Examination reveals heart sounds 1 and 2 present with no added sounds. Some crackles across the chest. Observations are normal.
Blood tests reveal:
Hb 99 g/l
MCV 74 fL
Platelets 196 * 109/l
WBC 14.8 * 109/l
Na+ 133 mmol/l
K+ 5.0 mmol/l
Urea 15 mmol/l
Creatinine 193 µmol/l
ESR 92 mm/hr
A chest x-ray is performed which reveals some diffuse alveolar infiltrates but no focal areas of consolidation. A sputum sample is analysed for MC and S and shows no malignant cells.
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?