Archives: MRCP Part 2

MRCP2-3916

As the medical doctor in charge of an acute medical admissions unit, you receive a 40-year old male patient with Alport’s syndrome and type 1 diabetes. He had a renal transplant from his brother two weeks ago and is currently on immunosuppressive therapy (tacrolimus and mycophenolate mofetil). The patient appears to be in good health, but his urine dipstick shows 3+ blood and protein. Upon examination, there are no apparent abnormalities.

The patient’s blood test results are as follows:

– Na+ 141 mmol/l
– K+ 4.7 mmol/l
– Urea 18.6 mmol/l
– Creatinine 288 µmol/l (baseline 80 µmol/l)
– eGFR 34 ml/min (baseline 82 ml/min)

What is the most likely cause of the patient’s acute kidney injury?

MRCP2-3917

A 68-year-old man presents to the clinic for a follow-up appointment after a recent humerus fracture. His blood tests reveal stage II chronic renal impairment, but his urinary albumin is within normal range. He has a history of hypertension and previous ischemic heart disease, and is motivated to control his blood pressure. His current medication includes ramipril at maximum dose. What should be his target blood pressure during his clinic visit?

Blood tests:
01/11/2018 08/09/2018
Na+ 142 mmol/l 140 mmol/l
K+ 4.5 mmol/l 4.6 mmol/l
Urea 5.1 mmol/l 5.3 mmol/l
Creatinine 118 µmol/l 110 µmol/l

MRCP2-3918

A 23-year-old female presents to the Emergency Department with blood in her urine. She produces a sample, demonstrates painless rose coloured macroscopic haematuria. She reports no past medical history except a single episode of a urinary tract infection about 4 years ago and a recent ‘cough and sore throat’ that had got better two weeks ago. Her family has no history of bladder or kidney problems except her mother having ‘shockwave treatment to her kidney tubes a few years ago’. She is sexually active with a regular partner, her last menstrual period was 2 weeks ago.

On examination, her abdomen is soft and non-tender with no organomegaly. Urine dip demonstrates 4+ blood, 1+ protein. Her blood tests are as follows:

Hb 125 g/l
Platelets 259 * 109/l
WBC 12.1 * 109/l

Na+ 139 mmol/l
K+ 4.8 mmol/l
Urea 5.6 mmol/l
Creatinine 72 µmol/l
CRP 3 mg/l

Beta HCG negative
HIV negative
CMV IgG positive
CMV IgM negative
EBV IgG positive
Anti-streptolysin titre positive

Chest radiography is unremarkable. Ultrasound of her renal tract shows normal sized kidneys with no hydronephrosis.

What is the diagnosis?

MRCP2-3920

A 25-year-old man presents to the emergency department with a six-day history of malaise, headache, and a sore throat. He has noticed blood in his urine on the last three occasions. He has no abdominal pain and is passing urine 3-4 times a day. He was diagnosed with coeliac disease three months ago after experiencing non-specific lethargy and weight loss. He is a smoker, consuming 20 cigarettes a day.

The patient feels hot and cold, and his vital signs show a blood pressure of 134/89 mmHg, heart rate of 65 beats per minute, respiratory rate of 22 breaths per minute, and a temperature of 39ºC. A urine sample obtained is brown with sediment and tests positive for blood and leukocytes.

On examination, his abdomen is soft and non-tender. His throat is red with pus seen on the tonsils. He is tender over the maxillary sinus on the left side and complains of congestion here. There is no meningism, and he is alert. He saw his GP three days earlier, who started benzylpenicillin and performed the following investigations.

Na+ 138 mmol/l
K+ 4.6 mmol/l
Urea 7.6 mmol/l
Creatinine 145 µmol/l

Throat swab commensal flora

Urine numerous red and white cell casts, no organisms seen

C3 normal
C4 normal
IgA 3.25 (normal range 0-0.5)
IgG 2.3 (normal range 2-3)
IgE 0.25 (normal range 0-0.5)

What is the likely diagnosis?

MRCP2-3924

A 35-year-old liver transplant recipient has been diagnosed with invasive candidiasis in the esophagus. The doctor has suggested starting intravenous fluconazole therapy.

Which of the following medications will require more frequent therapeutic drug monitoring while the patient is on fluconazole?

MRCP2-3925

A 70-year-old man with bipolar disorder is admitted from home, presenting with dehydration. He has a history of colonic resection with subsequent ileostomy, but further information is not available. His current medications include lithium bicarbonate, aspirin, and ramipril. On examination, his vital signs are stable, but he appears dehydrated. There is no evidence of bowel obstruction, and effluent is present in the ileostomy. Blood tests reveal high serum sodium but normal serum blood sugar. Renal function and full blood count results are pending. A urinary catheter is inserted, and intravenous fluid replacement is initiated. Which diagnostic test would be most useful in distinguishing between renal and extra-renal fluid loss?

MRCP2-3926

A 70-year-old male patient with chronic kidney disease (CKD) stage 4 secondary to diabetic nephropathy presented to the clinic with complaints of worsening fatigue and exertional breathlessness over the past two months. He denied any gastrointestinal symptoms or bleeding. The patient’s current medications included ramipril, bisoprolol, atorvastatin, and gliclazide.

Upon examination, the patient appeared pale but was euvolaemic. Cardiovascular, respiratory, and abdominal examinations were unremarkable. The patient’s blood results are as follows:

– Hb: 96 g/L (Male: 135-180, Female: 115-160)
– Platelets: 350 * 109/L (150-400)
– WBC: 6.5 * 109/L (4.0-11.0)
– Na+: 138 mmol/L (135-145)
– K+: 5.0 mmol/L (3.5-5.0)
– Urea: 11 mmol/L (2.0-7.0)
– Creatinine: 270 µmol/L (55-120)
– CRP: 3 mg/L (<5)
– Ferritin: 35 ng/mL (20-230)
– Transferrin saturations: 16% (20-40)
– Vitamin B12: 380 ng/L (200-900)
– Folate: 4.5 nmol/L (>3.0)
– Reticulocytes: 1.2% (0.5-1.5)

What is the most appropriate next step in management?

MRCP2-3927

A 55-year-old man presents to the renal outpatient department with complaints of fatigue and shortness of breath. He has a medical history of end-stage renal failure due to hypertension and is currently undergoing dialysis. His medication regimen includes ramipril, amlodipine, and doxazosin. On examination, an arterio-venous fistula is noted at his right forearm.

The patient’s blood tests reveal a hemoglobin level of 84 g/L (male: 135-180, female: 115-160), MCV of 85 fL (80-96), platelets of 189 * 109/L (150-400), WBC of 4.4 * 109/L (4.0-11.0), Na+ of 138 mmol/L (135-145), K+ of 4.8 mmol/L (3.5-5.0), urea of 28.1 mmol/L (2.0-7.0), ferritin of 88 µg/L (24-336), and transferrin saturation (TSAT) of 12% (20-50).

What would be the appropriate management strategy for this patient?

MRCP2-3928

A 52-year-old man arrives at the Emergency Department complaining of severe left-sided flank pain that has been ongoing for 4 hours. The pain is constant but fluctuates in intensity and has been accompanied by several episodes of vomiting.

The patient has a history of congestive heart failure, gout, and glaucoma. He was also recently diagnosed with HIV and began taking highly active antiretroviral therapy (HAART) six months ago.

Upon examination, the patient is not running a fever. His pulse is 96 beats per minute, and his blood pressure is 142/79 mmHg. His chest is clear, and his abdomen is soft, but he experiences tenderness in the left costovertebral angle when palpated.

The results of his urine dipstick are as follows:

pH 6.0
Specific gravity 1.020
Blood +++
Protein +

A CT KUB is ordered and reveals inflammatory stranding around the left kidney with mild hydronephrosis but no visible ureteric calculi.

The patient is admitted for hydration and pain relief but continues to experience symptoms for the next 24 hours. He undergoes intravenous pyelography, which reveals a filling defect in the mid-ureter.

Which of the patient’s medications is most likely responsible for his symptoms?

MRCP2-3929

A 16-year-old girl is admitted to the Acute Medical Unit with a 4-day history of vomiting and persistent diarrhoea accompanied by cramping abdominal pain. She has noticed fresh blood in her stool and is having difficulty maintaining her oral intake. She reports a weight loss of 1-2kg. She has no previous medical history.

Upon examination, she has a temperature of 38.5ºC and a heart rate of 122 bpm with a blood pressure of 100/70 mmHg. Her chest sounds are clear and heart sounds are normal. She has reduced skin turgor and dry mucous membranes. She is generally tender over her entire abdomen, but there is no guarding or palpable masses.

Investigations:

Hb 115 g/L Male: (135-180)
Female: (115 – 160)
Platelets 102 * 109/L (150 – 400)
WBC 15.2 * 109/L (4.0 – 11.0)
Na+ 147 mmol/L (135 – 145)
K+ 5.6 mmol/L (3.5 – 5.0)
Urea 12.8 mmol/L (2.0 – 7.0)
Creatinine 183 µmol/L (55 – 120)
CRP 155 mg/L (< 5) Blood film: schistocytes. What is the most appropriate next investigation given the likely diagnosis?