Archives: MRCP Part 2

MRCP2-3890

A 44-year-old female presents to the hyperacute stroke unit with expressive dysphasia and mild right sided upper limb weakness without sensory disturbance six hours after symptom onset. Despite being outside the thrombolysis window, a hyperacute CT head reveals multiple small infarcts in the left middle cerebral artery territory, while a simultaneous CT angiogram of her extra and intracranial vessels shows a string of beads appearance as reported by the radiologist. What is the most suitable subsequent investigation to request in order to identify the underlying cause of this woman’s strokes?

MRCP2-3891

A 38-year-old woman presents with generalised oedema. She has a history of excessive alcohol intake and smoking 10 cigarettes per day. She suffers from anxiety and mild eczema and has been experiencing weight loss and fatigue over the past few weeks and months. On physical examination, her BP is 140/80 mmHg, chest and abdominal examination is unremarkable. There is bilateral peripheral leg oedema. BMI is 22.

Initial investigations reveal:
Investigations Result Normal Values
Sodium (Na+) 144 mmol/l 135 – 145 mmol/l
Potassium (K+) 3.9 mmol/l 3.5 – 5.0 mmol/l
Urea 4.2 mmol/l 2.5 – 6.5 mmol/l
Creatinine (Cr) 98 µmol/l 50 – 120 µmol/l
Albumin 25 g/l 35 – 55 g/l
24-hour urinary protein collection 2.8 g/24 h < 0.2 g/24 h
Renal biopsy Focal segmental glomerulosclerosis

What is the most likely association with this disease in this patient?

MRCP2-3889

A 75-year-old man has been admitted with an ischaemic right limb and the vascular surgical team would like to perform a CT with contrast to investigate. He has a history of diabetes and heart failure. His blood tests are shown below:

Hb 135 g/l
Platelets 270 * 109/l
WBC 6 * 109/l

Na+ 140 mmol/l
K+ 4 mmol/l
Urea 6 mmol/l
Creatinine 140 µmol/l
eGFR 65 ml/min/1.73m2

What measures can be taken to prevent acute kidney injury in this patient?

MRCP2-3888

A 26-year-old factory worker presents after an accident at work. He suffered a crush injury when a heavy machine fell on his leg, and he was trapped for over an hour. The orthopaedic team cleared him of any fractures, but fasciotomies were performed due to concerns about compartment syndrome. However, his urine output over the last four hours was only 35 mL, despite a mean arterial pressure of 70 mmHg. His blood results showed elevated levels of creatine kinase, potassium, urea, and creatinine, with a normal haemoglobin level and pH of 7.35. What is the most important management plan to initiate?

MRCP2-3893

A 31-year-old male with a history of end-stage renal failure (ESRF) secondary to Alport syndrome underwent a deceased donor renal transplant. Genetic testing had previously revealed a mutation in the COL4A5 gene. After two weeks, his creatinine stabilized at 110 µmol/L. However, six months later, he experienced a sudden decrease in urine output and blood tests showed a rise in creatinine to 450 µmol/L. A transplant biopsy revealed linear deposition of immunoglobulin G (IgG) along the glomerular capillaries and crescentic glomerulonephritis. What is the most likely diagnosis?

MRCP2-3895

You assess a 67-year-old man with diabetic nephropathy in the renal outpatient clinic. He has chosen to undergo hospital hemodialysis and is waiting for fistula creation. He reports feeling fatigued and experiencing poor exercise tolerance. Despite being clinically euvolemic, his blood test results are as follows:

– Sodium (Na+): 134 mmol/L
– Potassium (K+): 5.6 mmol/L
– Bicarbonate (HCO3-): 21 mmol/L
– Urea: 29 mmol/L
– Creatinine: 480 µmol/L
– Hemoglobin (Hb): 89 g/L
– Mean corpuscular volume (MCV): 81 fL
– Ferritin: 500 ng/mL

What is the optimal approach to managing his anemia?

MRCP2-3892

A 50 year-old man presented for his regular check-up at the HIV clinic. He has been on highly-active antiretroviral therapy for 5 years and has been in good health. He has no significant medical history.

During his clinic visit, a urinalysis was conducted and showed 4+ protein and 1+ blood. The physical examination revealed slight swelling in both ankles, but no abnormalities were found in the cardiovascular, respiratory, or abdominal regions.

What is the probable diagnosis?

MRCP2-3898

A 35-year-old man, who works as a construction worker, is brought to the Emergency Department after collapsing at work. He attributes it to the hot weather but, upon further questioning, admits to experiencing extreme fatigue and muscle cramps during physical activity for as long as he can remember. His wife, who has come to the Emergency Department with him, confirms that he often complains of lethargy and muscle pains after work.

On examination, his blood pressure is 110/70 mmHg, pulse is 80/min and regular. He is of average height and his BMI is 25.

The following investigations were conducted:
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) 200 × 109/l 150 – 400 × 109/l
Sodium (Na+) 140 mmol/l 135 – 145 mmol/l
Potassium (K+) 3.2 mmol/l 3.5 – 5.0 mmol/l
Bicarbonate (HCO3-) 30 mmol/l 22 – 29 mmol/l
Creatinine (Cr) 90 µmol/l 50 – 120 µmol/l
24 hour urinary calcium 2.5 mmol 2.50 – 7.50 mmol

What is the most likely diagnosis for this patient?

MRCP2-3896

A 72-year-old male presents with a fractured neck of femur following a fall while getting out of the car. They are successfully managed with a dynamic hip screw, and are recovering on the ward.

He has a history of hypertension and chronic kidney disease (CKD), taking regular ramipril and amlodipine. He is normally independent at home, living with his wife. He currently smokes 15 cigarettes per day, and does not drink alcohol.

His FRAX score is calculated as 11% 10 year fracture risk, and he is investigated for secondary causes of fragility fractures. Results are below:

DEXA scan T-score: -3.1

Calcium 2.0 mmol/L (2.1-2.6)
Phosphate 1.8 mmol/L (0.8-1.4)
Parathyroid Hormone 89ng/L 10-65 ng/L
Vitamin D 10 nmol/L 25–100 nmol/L
Free thyroxine (T4) 12.1 pmol/L (9.0 – 18)

What is the most likely cause of his fragility fracture?

MRCP2-3894

A 56-year-old man presents to the general medical clinic with concerns about erectile dysfunction. He reports difficulty in initiating and maintaining an erection, despite having regular intercourse with his wife. He denies any other medical issues, except for an increase in stress due to work pressures. He works as a lawyer and is worried about potential job loss. His medical history includes well-controlled type 2 diabetes with metformin MR, gout, and a cholecystectomy. He has a BMI of 28 and is interested in trying medical treatment. On examination, there are no abnormalities to the external genitalia and a normal PR exam is noted. Blood tests are ordered for review in clinic, including HbA1c, renal function, liver function, testosterone, and full blood count. A random capillary glucose is 7.3mmol/l. What other appropriate measures should be taken at this time?