Archives: MRCP Part 2

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?

MRCP2-3930

A 45-year-old man with chronic kidney disease stage 5 due to autosomal-dominant polycystic kidney disease presents to the general nephrology clinic with complaints of increasing fatigue. He denies any changes in bowel habits or weight loss. On examination, his blood pressure is 120/56 mmHg, heart rate is 56 bpm, respiratory rate is 18/min, and Sats are 99% on air. His abdomen is soft and non-tender with palpable kidneys and an irregular liver edge. He is euvolemic.

Lab results show a hemoglobin level of 78 g/l, platelets of 167 * 109/l, WBC of 7 * 109/l, and ferritin of 95 ng/mL. B12 and folate levels are within normal range.

What is the most appropriate next step?

MRCP2-3910

A 36-year-old man of African descent presented to the HIV clinic for a routine check-up. He had been on HAART for 4 years but admitted to frequently forgetting to take his medication.

During the examination, the patient was found to have pitting edema in both ankles. A urinalysis performed in the clinic showed 4+ protein and 1+ blood.

Further blood tests revealed a CD4 count of 130 cells/mm3 (normal range: 500-1500) and normal serum complement levels. A renal biopsy was performed, which showed collapsing FSGS.

What is the most likely diagnosis for this patient?

MRCP2-3911

A 56-year-old woman with end stage renal failure due to hypertension presents with complaints of increasing fatigue and thirst. She is currently undergoing renal replacement therapy through haemodialysis and is taking Levemir, NovoRapid, ramipril, aspirin, simvastatin, calcium carbonate, and erythropoietin. On examination, her pulse rate is 84 beats per minute and regular, and her blood pressure is 138/65 mmHg. The jugular venous pressure is visible 2 cm above the clavicle (prior to dialysis), the lung bases are clear, and there is no peripheral oedema. A functioning radiocephalic arteriovenous fistula is present in her left arm.

Her pre-dialysis blood tests reveal a haemoglobin level of 105 g/L (115-165), sodium level of 134 mmol/L (137-144), potassium level of 4.7 mmol/L (3.5-4.9), urea level of 34 mmol/L (2.5-7.5), creatinine level of 437 μmol/L (60-110), corrected calcium level of 2.78 mmol/L (2.2-2.6), phosphate level of 1.79 mmol/L (0.8-1.4), and parathyroid hormone level of 724 ng/L (15-65).

What is the most likely diagnosis?

MRCP2-3912

A 57 year-old woman comes in for her annual diabetic check-up. She has been diagnosed with type 2 diabetes mellitus for 13 years and is currently only taking metformin for her diabetes. During her last diabetes check-up 1 week ago, her HbA1c was found to be 40 mmol/mol. She has a medical history of peripheral vascular disease and migraine. Additionally, she has a smoking history of 20 pack years and drinks 5-10 units of alcohol per week. Upon examination, her pulse rate is 86 beats per minute and her blood pressure is 126/70 mmHg. Blood tests reveal a sodium level of 140 mmol/l, potassium level of 3.4 mmol/l, urea level of 7.0 mmol/l, and creatinine level of 105 µmol/l. Urinalysis shows negative results for protein, glucose, leucocytes, and nitrites. However, a 24-hour urine sample indicates 190 mg of albumin in her urine.

What would be the most appropriate next step in managing her renal function?

MRCP2-3913

A 70-year-old Indian male presents with left loin pain and occasional frank haematuria. He reports the symptoms started 3 months ago during a visit to Mumbai but have been getting progressively worse over the past 5 days. He also reports gradual weight loss and reduced appetite as well as a non-productive cough.

His past medical history includes type 2 diabetes mellitus, hypertension and hypercholesterolaemia. On examination, his temperature is 37.8 degrees and he is haemodynamically stable.

Abdominal examination reveals a significant swelling in his left scrotum, which does not empty on lying flat. The abdomen is otherwise soft and bowel sounds are present are normal. Lastly, bilateral lower limb swelling is noted to the top of both thighs. A urine dip reveals pH 6.5 4+ blood 1+ protein 1+ leucocyte 1+ nitrite. An initial chest radiograph reveals multiple round opacities in both lung fields. Blood tests are awaited.

Which diagnostic test is most likely to uncover the underlying condition?