Archives: MRCP Part 2

MRCP2-3977

A 19 year-old man presented to his physician complaining of facial puffiness and leg swelling that had developed over the past few weeks. He had no significant medical history and no family history of note. He was not taking any regular medications.

During the physical examination, his pulse was found to be 90 beats per minute and his blood pressure was 140/80 mmHg. Cardiovascular, respiratory and abdominal examination did not reveal any abnormalities. Urinalysis showed 4+ protein and 1+ blood, but was negative for glucose.

The following laboratory results were obtained:
– Hemoglobin: 138 g/l
– Platelets: 185 * 109/l
– White blood cells: 6.6 * 109/l
– Sodium: 144 mmol/l
– Potassium: 4.0 mmol/l
– Urea: 5.5 mmol/l
– Creatinine: 78 µmol/l
– Serum albumin: 20 g/L
– 24 hour urine protein: 5.1 g (<0.2) A renal biopsy was performed and showed podocyte fusion on electron microscopy. What is the most appropriate next step in the treatment of this patient?

MRCP2-3975

A 28-year-old woman with type 1 diabetes is admitted to the hospital due to diabetic ketoacidosis. She has a history of three retinal photocoagulation episodes for diabetic retinopathy. After receiving adequate fluid resuscitation, she makes a good recovery. Her blood tests reveal mild renal impairment with a creatinine level of 99 μmol/L (eGFR 60 ml/min/1.73m2), and her blood pressure is 116/43 mmHg. She is currently taking Lantus and NovoRapid insulins as her only medications. A renal ultrasound shows no abnormalities, and a random urine sample is sent to the laboratory for analysis. The microscopy results are unremarkable, and the urinary albumin:creatinine ratio (ACR) is reported as 17 mg/mmol (<2.5). What is the most appropriate action to take?

MRCP2-3971

A 65-year old man with a history of non-small cell lung cancer underwent a right lower lobectomy a year ago. Recently, he had a chest and abdominal CT scan which revealed hepatic mass lesions and hilar lymphadenopathy. He is currently experiencing malaise and fatigue. Upon examination, his urinalysis showed protein +++ and his 24-hour urine protein was 2.7 g/24hr. His serum urea was 30 mmol/L (2.5-7.5) and his serum creatinine was 450 µmol/L (60-110). A renal biopsy revealed focal deposition of IgG and C3 with a granular pattern. What is the most likely diagnosis?

MRCP2-3979

A 15-year-old female patient is referred to the hospital by her GP due to ankle and facial swelling, as well as dark urine that has been present for four days. She had visited the practice two weeks ago with pharyngitis. During examination, her blood pressure is found to be 165/100 mmHg, and her urine dipstick shows a strong positive for protein and blood.

Upon admission, the patient is diagnosed with acute kidney injury, with a creatinine level of 189 μmumol/l and urea level of 17.8 mmol/l. A renal ultrasound scan reveals normal sized kidneys with no signs of obstruction. After controlling her blood pressure, a renal biopsy is performed.

What are the expected histological features on light microscopy?

MRCP2-3966

A 72-year-old man is referred to hospital by his GP.
He has been treated for essential hypertension, with a daily dose of bendroflumethiazide 2.5 mg and triamterene 150 mg.
Routine investigations reveal:
Serum sodium 136 mmol/L (137-144)
Serum potassium 6.1 mmol/L (3.5-4.9)
Serum urea 6.5 mmol/L (2.5-7.5)
Serum creatinine 95 µmol/L (60-110)
His blood pressure is measured at 138/88 mmHg. His electrocardiogram is normal. The GP has stopped the triamterene today.
What is the most appropriate course of action?

MRCP2-3968

A 57-year-old man presents to the renal clinic for a follow-up of his stable stage 4 CKD, which is caused by hypertensive nephrosclerosis. During his visit, his blood work is taken and the results are phoned to the ward. The results are as follows:

Sodium: 138 mmol/L (137-144)
Potassium: 4.2 mmol/L (3.5-4.9)
Creatinine: 310 μmol/L (stable) (60-110)
Corr calcium: 1.86 mmol/L (2.2-2.6)
Phosphate: 1.24 mmol/L (0.8-1.4)
PTH: low

Which medication is the probable culprit for his condition?

MRCP2-3980

A 55-year-old man presents to his GP with complaints of weight loss and increased frequency of stool over the past four months. He had a severe case of influenza one month ago and has been feeling more stressed at work. He also reports ankle swelling and frothy urine. On examination, he has evidence of pitting edema and a 2 cm firm non-tender liver edge. Investigations reveal low hemoglobin, low MCV, elevated ESR, and elevated bilirubin and alkaline phosphatase. CXR shows bilateral pleural effusions. What is the most important investigation to guide further management?

MRCP2-3963

A 50-year-old man, previously healthy and active, presents to the emergency department with a six-week history of back pain, malaise, and hiccups. He experienced an episode of hematuria three days prior to admission and has no history of respiratory symptoms. On examination, he appears unwell with a pulse of 120, BP 105/80 mmHg, temperature 36.7°C, and oxygen saturation of 95% on air. Laboratory investigations reveal low hemoglobin levels, normal white cell count, low sodium levels, high potassium levels, high urea levels, high creatinine levels, and low pH levels. His ECG shows marked tenting of the T waves. He is urgently transferred for dialysis and further investigations. A chest x-ray shows no signs of heart failure or consolidation. His urine dip is positive for protein and blood only. An ultrasound of the renal tract is normal, but a renal biopsy reveals acute glomerulonephritis with linear immunofluorescence staining. He tests positive for antiglomerular basement membrane antibody, and a diagnosis of Goodpasture’s disease is made. Besides hemodialysis, what other therapeutic modality is likely to be beneficial in the next few days?

MRCP2-3961

A 70-year-old patient with chronic kidney disease secondary to renovascular disease presents for follow-up. His recent blood work reveals anemia with a hemoglobin level of 102 g/L (130-180) and an MCV of 87 fL (80-96). His eGFR is 15 ml/min/1.73 m2, and he is currently taking oral iron supplements and darbepoetin alfa 60 mg weekly. The patient’s ferritin level is 150 μg/L (15-300), and transferrin saturation is 18% (20-40%). C-reactive protein is <5 mg/L (<10). What is the most appropriate course of action to manage his anemia?

MRCP2-3958

A 36-year-old woman presents to the Emergency Department with complaints of severe flank pain, fever and difficulty urinating for the past four days. The fever is high grade and associated with chills and shivers. On examination, her blood pressure is 110/70 mmHg and her heart rate is 120 bpm. Severe flank tenderness is present on the left side.

She is immediately started on intravenous rehydration with crystalloids and empirical antibiotic therapy. A plain computed tomography (CT) abdomen is performed, which shows evidence of a ureteral calculus measuring 10mm, with hydroureteronephrosis. In addition, there is evidence of perinephric fat stranding of the left kidney.

What is the best course of action for managing this patient?