Archives: MRCP Part 2

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?

MRCP2-3891

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?

MRCP2-3899

A 28-year-old man presents with his third episode of fainting in the past six months. He reports trying to stay hydrated in hot weather but often feels dizzy. He has no regular medications. On examination, his BP is 120/80 mmHg, pulse is 80/min and regular. BMI is 25. No abnormalities are found. Lab results show:
Hb: 140 g/l (normal range: 135 – 175 g/l)
WCC: 7.5 × 109/l (normal range: 4.0 – 11.0 × 109/l)
PLT: 200 × 109/l (normal range: 150 – 400 × 109/l)
Na+: 140 mmol/l (normal range: 135 – 145 mmol/l)
K+: 3.3 mmol/l (normal range: 3.5 – 5.0 mmol/l)
Bicarbonate: 30 mmol/l (normal range: 22 – 29 mmol/l)
Cr: 80 µmol/l (normal range: 50 – 120 µmol/l)

What is the most likely diagnosis for this patient?

MRCP2-3886

A 65-year-old woman presents to the acute medical unit with complaints of frequent urination and excessive thirst. She reports having to wake up at least three times every night to urinate and constantly feeling thirsty. Her medical history includes hypertension, ischaemic heart disease, and bipolar disorder, and she is currently taking aspirin, lithium, and bisoprolol. An overnight water deprivation test was conducted, and the results are as follows:

– Na+ 145 mmol/l (137-144)
– K+ 4.5 mmol/l (3.5-4.9)
– Urea 11.5 mmol/l (2.5-7.0)
– Creatinine 188 µmol/l (60-110)
– Random blood glucose 7.2 mmol
– Serum osmolality 370 mosmol/kg (278-300)
– Urine osmolality 165 mosmol/kg (350-1000)

A d DAVP (1-deamino-8-D-arginine vasopressin) test was performed, but the urinary osmolality remained unchanged. What is the most likely diagnosis?

MRCP2-3881

A 44-year-old man with a 15-year history of osteoarthritis has been referred to the nephrologists due to a serum creatinine level of 210 µmol/l. He was diagnosed with diabetes mellitus and essential hypertension one year ago and is currently taking ramipril 10 mg, aspirin 75 mg, diclofenac 150 mg, and atorvastatin 10 mg daily. On examination, his BP was 110/70 mmHg, and systemic examination was normal. Investigations revealed low haemoglobin levels, high urea and creatinine levels, and normal sodium, potassium, corrected calcium, phosphate, albumin, and 24-h urinary protein collection. His echocardiogram was normal, and renal ultrasound scan showed unobstructed echogenic kidneys with the right kidney measuring 9.4 cm and the left kidney measuring 8.8 cm. What is the most likely cause of his renal impairment?

MRCP2-3887

A 72 year old woman with a history of type 2 diabetes mellitus, hypertension, and previous myocardial infarction arrives at the Emergency Department complaining of abdominal pain and profuse diarrhea for the past two days, which has turned bloody in the last 24 hours. Her vital signs are as follows: temperature of 37.2º, heart rate of 102 beats per minute, and blood pressure of 106/74 mmHg. Upon examination, her heart sounds are normal, chest is clear, and she has a diffusely tender abdomen.

Lab results show a hemoglobin level of 10.4 g/dl, platelets at 64 * 109/l, WBC at 14.2 * 109/l, urea at 10 mmol/l, creatinine at 154 µmol/l, bilirubin at 56 µmol/l, and CRP at 125 mg/l. A blood film reveals fragmented red blood cells. Based on the likely diagnosis, what is the most appropriate course of action for this patient?

MRCP2-3885

A 68-year-old-male presents to the clinic with complaints of fleeting joint pains and a progressive rash on both legs. He has been self-medicating with over the counter painkillers for his chronic back pain for the past six weeks. He has a history of hypertension.

Upon examination, there is no evidence of active synovitis, but there is a symmetrical eruption of palpable, red-purple papular lesions across the extensor surfaces of both legs. His heart sounds are normal, and his abdomen is soft and non-tender. His clinic blood pressure reading is 146/88 mmHg, and his oxygen saturations are at 99% on room air.

Lab results show Hb 132 g/l, Platelets 155* 109/l, WBC 9.9 * 109/l, Neuts 5.1 * 109/l, Lymphs 1.0 * 109/l, Eosin 2.5 * 109/l, Na+ 135 mmol/l, K+ 5.1 mmol/l, Urea 7.3 mmol/l, Creatinine 256 mol/l, and CRP 6 mg/l.

What is the most likely diagnosis?

MRCP2-3882

A 32-year-old woman presents to the Emergency Department with visible haematuria. She has no past medical history of note, other than a recent cold, which quickly resolved. She has no history of kidney stones and no history of weight loss, fatigue or fevers.
There is no pain or tenderness on examination of her abdomen, and her urine is noted to be stained pink-red. An abdominal computerised tomography (CT) is performed which is reported as normal.
Her blood pressure is 150/90 mmHg.
Investigation:
s
Haemoglobin (Hb) 130 g/l 115–155 g/l
White cell count (WCC) 7.5 × 109/l 4.0–11.0 × 109/l
C-reactive protein (CRP) 8 mg/l < 3 mg/l
Creatinine (Cr) 140 µmol/l 50–120 µmol/l
Urea 6.5 mmol/l 2.5–6.5 mmol/l
Potassium (K+) 5.6 mmol/l 3.5–5.0 mmol/l
Sodium (Na+) 138 mmol/l 135–145 mmol/l
Compliment C3 110 mg/dl 80–160 mg/dl
Compliment C4 40 mg/dl 20–50 mg/dl
Antinuclear antibody (ANA) Negative
Antineutrophil cytoplasmic antibodies (ANCA) Negative
Glomerular basement membrane (GBM) Negative
Electrophoresis No paraprotein
What is the most likely diagnosis?

MRCP2-3884

A 57-year-old man with metastatic small cell lung carcinoma is admitted to hospital with vomiting, ankle swelling and pruritus. He recently completed a course of palliative chemotherapy. He has a history of chronic obstructive pulmonary disease and hypertension and is currently taking morphine sulphate (MST) for pain relief.

During examination, he appears cachectic with peripheral oedema and skin excoriations. His heart rate is 96 beats per minute and blood pressure is 140/85 mmHg.

The following tests were conducted:

– Hb: 134 g/l
– Platelets: 185 * 109/l
– WBC: 5.5 * 109/l
– Na+: 146 mmol/l
– K+: 5.4 mmol/l
– Urea: 23 mmol/l
– Creatinine: 420 µmol/l

Urine dip shows blood +, urine osmolality is 350 mOsm/L, urinary sodium is 45 mEq L, and microscopy reveals red cells and casts.

What is the most suitable pain relief option for this patient?

MRCP2-3880

A 26-year-old man presents at the diabetic clinic with ++++ proteinuria and bilateral leg swelling that began one week ago following a minor upper respiratory infection. He has been insulin-dependent for five years but has no signs of neuropathy, and his eye screening reveals no background retinopathy. His random glucose level in the clinic is 5.9. What is the probable diagnosis?