Archives: MRCP Part 2

MRCP2-3938

A 35-year-old construction worker presents to the Emergency Department with severe pain in his left side and dark urine. He denies fever but reports seeing his primary care physician a few days ago for urinary frequency and burning, and was prescribed trimethoprim which resolved the symptoms. The pain suddenly onset and is so intense that he cannot walk. He also experiences nausea and has vomited twice. The pain radiates to his groin. Vital signs are temperature 37.5°C, blood pressure 120/80 mmHg, pulse rate 100 bpm, and respiratory rate 16 breaths per minute. Physical examination of the chest and heart is normal. The abdomen is soft and non-tender, with no guarding. Analgesia is administered.

Lab results show:
– Creatinine (Cr): 90 µmol/l (normal range: 60-110 µmol/l)
– Urea: 6.0 mmol/l (normal range: 2.5-7.5 mmol/l)
– Hemoglobin (Hb): 130 g/l (normal range: 135-175 g/l)
– Potassium (K+): 3.8 mmol/l (normal range: 3.5-5.0 mmol/l)
– Corrected calcium: 2.50 mmol/l (normal range: 2.2-2.7 mmol/l)
– White cell count (WCC): 12 × 109/l (normal range: 4.0-11.0 × 109/l)
– Erythrocyte sedimentation rate (ESR): 15 mm/h (normal range: 1-20 mm/h)

What is the most appropriate initial treatment for this patient?

MRCP2-3943

A 40-year-old woman of Afro-Caribbean descent presents to the hospital with a two-week history of fatigue and worsening swelling in her lower limbs. She was diagnosed with systemic lupus erythematosus six years ago and her creatinine levels have been gradually increasing from 120 µmol/l to 260 µmol/l over the past six months.

During the examination, her blood pressure is found to be 180/118 mmHg, and she has significant swelling in her ankles and feet, along with periorbital edema. A urine dip test reveals 4+ protein, and a 24-hour urine collection shows 4.6g protein. A renal biopsy is performed by the renal physicians, which confirms membranous lupus nephritis. Along with angiotensin-converting enzyme inhibitors, statins, and anti-hypertensives, what is the most appropriate immediate treatment?

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?

MRCP2-3939

A 63-year-old male presents with confusion. He lives alone and there is no available collateral history. He has a medical history of COPD and heart failure and is currently taking ramipril, spironolactone, and bendroflumethiazide. The following blood results were obtained:

Hb 135 g/l
Platelets 242 * 109/l
WBC 12.8 * 109/l
Neuts 8.8 * 109/l
Na+ 138 mmol/l
K+ 3.9 mmol/l
Urea 10.8 mmol/l
Creatinine 96 µmol/l
Chloride 110 * 109/l
Glucose 5.2 mg/l
Bicarbonate 10 mEq/L

What is the most probable cause of the acidosis?

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?

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?

MRCP2-3945

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?

MRCP2-3942

A 64-year-old man attends renal transplant clinic as part of the preliminary workup to be considered as a living kidney donor. The patient’s 26-year-old daughter has stage 5 chronic kidney disease secondary to congenital hydronephrosis, and will shortly require dialysis unless she receives a donated kidney. Upon arrival at the appointment, the patient expresses his hopefulness that he will be found to be a suitable kidney donor for his daughter.

What is the one absolute contraindication that would prevent this patient from being a living kidney donor for his daughter?