Archives: MRCP Part 2

MRCP2-3950

A 23-year-old woman visits her primary care physician (PCP) with complaints of visible blood in her urine that started 2 days after recovering from a recent upper respiratory tract infection. She has a medical history of seasonal allergies and occasional migraines. She takes over-the-counter antihistamines and ibuprofen as needed.
During the physical examination, her blood pressure is 130/80 mmHg, and her chest and abdominal exams are normal. There is no swelling in her extremities.
The following laboratory results are obtained:
Test Result Normal Range
Potassium (K+) 4.2 mmol/L 3.5 – 5.0 mmol/L
Sodium (Na+) 142 mmol/L 135 – 145 mmol/L
Creatinine (Cr) 150 µmol/L 50 – 120 µmol/L
Urea 13.5 mmol/L 2.5 – 6.5 mmol/L
Urine Culture Negative, red blood cells 2+, protein 1+
Urine Microscopy White blood cells and red cell casts
Renal Biopsy Diffuse mesangial proliferation and extracellular matrix expansion. A few necrotising lesions with crescent formation are noted.
What is the most appropriate next step in the management of her condition?

MRCP2-3948

A 45-year-old man with diabetic renal disease underwent a cadaveric renal transplant. On the fourth day after surgery, his creatinine level was 140 µmol/L (60-110 µmol/L). He is currently taking high dose prednisolone, azathioprine, and ciclosporin for immunosuppression. His urine output was initially good at 60 ml per hour, but decreased to 40 ml per hour on the sixth day. Repeat blood tests showed that his creatinine level had increased to 210 µmol/L (60-110 µmol/L). He has no fever, with a pulse of 80 and a blood pressure of 150/80 mmHg. He appears to be euvolaemic and is not experiencing any abdominal pain.

What is the most appropriate next step in managing this patient?

MRCP2-3956

A 65-year-old man has been referred to the renal outpatient clinic by his GP. He was put on an ACE inhibitor for poorly-controlled hypertension, but after a week, his GP noticed a significant decline in his renal function upon checking his urea and electrolytes. An MR angiogram revealed that his right renal artery is patent, but there is stenosis in his left renal artery. During examination, his BP was 149/90 mmHg, urinalysis was negative, and his physical examination was normal.

What is the most appropriate course of action?

MRCP2-3954

A 25-year-old traveler from the UK is diagnosed with malaria following a 2-week history of headaches, cyclic fever, fatigue, and joint pains while on vacation in Zambia. She has no significant medical history and is generally healthy.

The patient is admitted to the hospital and started on oral chloroquine for symptom relief. However, her condition worsens over the next day. Nursing staff notes that her urine output has significantly decreased despite IV fluid therapy.

Her blood results are as follows:

s
Sodium (Na+) 140 mmol/l 135 – 145 mmol/l
Potassium (K+) 5.8 mmol/l 3.5 – 5.0 mmol/l
Urea 48 mmol/l 2.5 – 6.5 mmol/l
Creatinine (Cr) 710 µmol/l 50 – 120 µmol/l
Haemoglobin (Hb) 90 g/l 135 – 175 g/l
Mean corpuscular volume (MCV) 82 fl 80 – 100 fl
White cell count (WCC) 5.5 × 109/l 4.0 – 11.0 × 109/l
Platelets (PLT) 180 × 109 /l 150 – 400 × 109/l
Blood film +++ for dengue virus

The patient is catheterized, and only 60 ml of dark urine is drained. She is given treatment to address her hyperkalemia.

What is the most appropriate next step in the management of this patient?

MRCP2-3951

An 80-year-old man was admitted to medical receiving with urinary retention after experiencing urinary hesitancy for several months. He had been unable to pass urine for a few days before admission. A urinary catheter was inserted, revealing a residual urine volume of 1200 mls. A renal tract ultrasound scan confirmed an enlarged prostate, which was also detected on PR examination. Currently, he is passing 3500 ml of clear urine daily and reports drinking around 2000 mls of water daily. He has no significant medical history and is not taking any regular medication. What would be the most appropriate course of action?

MRCP2-3959

A 68-year-old man with a history of hypertension presents to the Emergency Department with complaints of dysuria, flank pain, fever and chills for the past 2 days. He is currently taking metoprolol and hydrochlorothiazide for his hypertension. Upon examination, his vital signs are as follows: temperature 39.3 °C, blood pressure 100/60 mmHg, pulse 120/min, respiration 28/min and oxygen saturation 98% on room air. Mild tenderness is noted at the left costovertebral angle, but the rest of the physical examination is unremarkable. A chest X-ray is performed and comes back normal. The urine dipstick is positive for blood, protein and nitrites, prompting blood and urine analysis and cultures. What is the most appropriate course of action for management?

MRCP2-3957

A 57-year-old patient with chronic renal failure was admitted to the hospital after experiencing a gastrointestinal bleed. During the examination, the patient’s blood pressure was measured at 148/90 mmHg, with a pulse of 88 beats per minute, regular. A rectal examination revealed melaena stool.

Further investigations showed that the patient’s haemoglobin levels were at 109 g/L (130-180), MCV at 80 fL (80-96), serum sodium at 142 mmol/L (137-144), serum potassium at 5.1 mmol/L (3.5-4.9), serum urea at 19 mmol/L (2.5-7.5), and serum creatinine at 450 µmol/L (60-110).

Two weeks prior, investigations at the clinic showed that the patient’s haemoglobin levels were at 118 g/L (130-180), MCV at 84 fL (80-96), serum sodium at 139 mmol/L (137-144), serum potassium at 4.7 mmol/L (3.5-4.9), serum urea at 9 mmol/L (2.5-7.5), and serum creatinine at 250 µmol/L (60-110).

What is the most appropriate next step in managing this patient?

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?

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?

MRCP2-3962

A 49-year-old patient with type 1 diabetes and chronic kidney disease presents for a check-up. His recent blood tests reveal a haemoglobin level of 112 g/L (130-180), MCV of 87 fL (80-96), sodium of 133 mmol/L (137-144), potassium of 4.3 mmol/L (3.5-4.9), urea of 19.1 mmol/L (2.5-7.5), creatinine of 267 μmol/L (60-110), ferritin of 150 μg/L (15-300), C reactive protein of <5 mg/L (< 10), and an eGFR of 24 ml/min/1.73 m2. What is the most appropriate course of action for managing his anaemia?