Archives: MRCP Part 2

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?

MRCP2-3957

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?

MRCP2-3936

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?

MRCP2-3937

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?

MRCP2-3940

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?

MRCP2-3941

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?

MRCP2-3945

A 57-year-old man has been referred to the metabolic medicine clinic by his urologist due to repeated episodes of renal stones over the past few years. The patient has experienced multiple attacks of right-sided ureteric colic with the presence of renal calculi demonstrated on ultrasound. Despite maintaining his hydration level, the patient had a new episode of left-sided ureteric colic two months ago, which required lithotripsy and an ureteric stent. The patient is now symptom-free but is keen to consider interventions to reduce his risk of recurrent attacks.

The patient has a limited past medical history, with only a previous diagnosis of hypercholesterolaemia and a previous appendicectomy. He takes simvastatin 40 mg daily and works full time as a bus driver. Investigations organised following clinic review show elevated urinary calcium levels and biochemical analysis of calculi indicates calcium phosphate.

What is the appropriate management plan to reduce the patient’s risk of recurrent renal stones?

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?