Archives: MRCP Part 2

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?

MRCP2-3959

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?

MRCP2-3956

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?

MRCP2-3937

A 35-year-old man presents to the clinic with complaints of chest pain. His past medical history includes high cholesterol levels, which are currently being managed by his primary care physician. His father had a heart attack at the age of 45.
During the physical examination, his blood pressure was 140/90 mmHg, BMI was 30 kg/m2, his lungs were clear, and his abdomen was unremarkable.
The following investigations were conducted:
Sodium (Na+) 142 mmol/l 135 – 145 mmol/l
Potassium (K+) 4.2 mmol/l 3.5 – 5.0 mmol/l
Urea 6.0 mmol/l 2.5 – 6.5 mmol/l
Creatinine (Cr) 90 μmol/l 50 – 120 µmol/l
C-reactive protein (CRP) 8 mg/l < 10 mg/l
Haemoglobin (Hb) 140 g/l 135 – 175 g/l
White cell count (WCC) 7.0 × 109/l 4.0 – 11.0 × 109/l
Platelets (PLT) 300 × 109/l 150 – 400 × 109/l
Erythropoietin level Normal
What further investigation should be considered?

MRCP2-3936

A 32-year-old man presents to the clinic after experiencing a cold and sore throat, complaining of passing dark urine. He reports a previous episode of blood in the urine after a sore throat. On examination, his blood pressure is slightly elevated at 140/88 mmHg. All other physical findings are normal. Laboratory tests show a hemoglobin level of 120 g/L (normal range: 130-170 g/L), a white blood cell count of 5.8 x 10^9/L (normal range: 4.0-11.0 x 10^9/L), a platelet count of 150 x 10^9/L (normal range: 150-400 x 10^9/L), a sodium level of 138 mmol/L (normal range: 135-145 mmol/L), a potassium level of 4.2 mmol/L (normal range: 3.5-5.0 mmol/L), and a creatinine level of 130 µmol/L (normal range: 60-110 µmol/L). The urine test shows ++ blood and + protein. Which of the following tests is most likely to confirm the diagnosis?

MRCP2-3941

A 70-year-old woman with osteoporosis and hypertension presents to the Emergency department after falling and fracturing her wrist. She has a history of chronic renal failure (CKD stage 2) and is currently taking ramipril, alendronate, Calcichew, and aspirin. Her fracture is treated with a local haematoma block and she is discharged with diclofenac and codeine phosphate. Five days later, she visits her GP complaining of feeling unwell, nauseated, and having decreased urine output. Blood tests reveal a significant increase in creatinine levels and 1+ protein in her urine. What is the most likely mechanism of renal decline in this patient?

MRCP2-3944

A 32-year-old man presents to the hospital with visible blood in his urine. He recently arrived in the country from Nigeria and is not currently taking any medications. Upon examination, his blood pressure is 130/80 mmHg and he denies any other symptoms. The following investigations were conducted:

– Haemoglobin: 114 g/L (130-180)
– MCV: 72 fL (80-96 fL)
– Reticulocyte count: 4.9% (0.5-2.4)
– Serum sodium: 134 mmol/L (137-144)
– Serum potassium: 3.8 mmol/L (3.5-4.9)
– Serum urea: 8.0 mmol/L (2.5-7.5)
– Serum creatinine: 120 µmol/L (60-110)
– C reactive protein: 8 mg/L (<10)
– Urine dipstick: Protein +, Blood ++++

What is the most likely cause of his haematuria?

MRCP2-3940

A 63-year-old carpenter presents to the clinic with complaints of nausea and fatigue. He has a history of hypertension and is currently taking indapamide and amlodipine. On examination, he appears pale with a BP of 150/90 mmHg, a pulse of 75 and regular, and a BMI of 21. Further investigations reveal a haemoglobin level of 100 g/L, MCV of 77 fL with basophilic stippling on the film, white cell count of 8.8 ×109/L, platelets of 192 ×109/L, serum sodium of 140 mmol/L, serum potassium of 5.3 mmol/L, creatinine of 198 µmol/L, and 24-hour urinary protein of 1.8 g.

What is the most important management approach for his underlying condition?

MRCP2-3946

A 70-year-old man with a history of COPD is admitted with a severe pneumonia and AKI. His central venous pressure is 4 and his arterial blood gas shows:
pH 7.25 (7.35-7.45)
Bicarbonate 11 mmol/L (22-28)
BE -12 mmol/L (±2)
pCO2 9.0 kPa (4.7-6.0)
pO2 9.5 kPa (11.3-12.6)
His venous bloods reveal:
Sodium 132 mmol/L (137-144)
Potassium 5.5 mmol/L (3.5-4.9)
Urea 21.5 mmol/L (2.5-7.0)
Creatinine 410 μmol/L (60-110)
What is the most appropriate course of treatment?

MRCP2-3947

A 83-year-old woman is admitted to the general medicine ward due to vomiting and diarrhea for 48 hours. She has a medical history of osteoarthritis and hypertension and is taking the following medications:

– Paracetamol 1 g qds po
– Ibuprofen 400 mg tds po
– Ramipril 2.5 mg od po
– Zopiclone 3.75 mg od po

During the examination, she appears unwell with a temperature of 37.2°C, pulse of 95, and blood pressure of 90/50 mmHg. Her oxygen saturation on air is 92%. Her jugular venous pressure is difficult to visualize while lying flat. Her abdomen is soft, and her respiratory examination and chest x-ray are normal.

The nurses report that she has not passed urine four hours into admission. Some of her blood test results are as follows:

– Haemoglobin 13.3 g/dL (13-18)
– White cell count 11 ×109/L (4-11)
– Urea 15 mmol/L (2.5-7.5)
– Creatinine on admission 150 µmol/L (60-110)
– Creatinine 3 months ago 80 µmol/L (60-110)

What is the best next step in managing this patient?