Archives: MRCP Part 2

MRCP2-3876

You are urgently requested to review a 68-year-old woman who has been admitted to the Emergency Department. She has a past medical history of chronic obstructive pulmonary disease. She is currently complaining of worsening shortness of breath.

Upon examination, her blood pressure is 100/70 mmHg and her heart rate is 110 bpm. There are wheezes heard on auscultation of the chest. Both legs are swollen up to the knees.

The following investigations have been carried out:

Sodium (Na+) 138 mmol/l 135–145 mmol/l
Potassium (K+) 4.8 mmol/l 3.5–5.0 mmol/l
Urea 12 mmol/l 2.5–6.5 mmol/l
Creatinine (Cr) 120 µmol/l 50–120 µmol/l
Haemoglobin (Hb) 110 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

What is the most appropriate treatment option for this patient?

MRCP2-3878

A 28-year-old woman who is 13 weeks pregnant presents at the outpatient clinic with a sustained blood pressure reading of 170/92 mmHg. She has no significant medical history and has been feeling well with no symptoms. On examination, there are no abnormalities except for protein (+) and blood (+) in her urine. Fundoscopy shows no abnormalities, and an ultrasound of her kidneys reveals both to be of equal size at 9-10 cm. What is the probable cause of her hypertension?

MRCP2-3873

You are consulted to see a 67-year-old female on the renal dialysis unit. According to the nursing staff, she developed a headache shortly after starting dialysis and has since become confused. The patient has a medical history of myeloma, which has resulted in a rapid decline in renal function. Upon examination, you observe that her Glasgow coma score is 13 (M5, V5, E3) and she is experiencing myoclonic jerks. Fundoscopy reveals papilloedema. The patient’s medication history includes a fentanyl patch and regular paracetamol.

The patient’s pre-dialysis blood work is as follows:

Hb 105 g/l Na+ 138 mmol/l
Platelets 210 * 109/l K+ 6.8 mmol/l
WBC 8.8 * 109/l Urea 46 mmol/l
Neuts 4.2 * 109/l Creatinine 588 µmol/l

What is your plan for managing this patient?

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?

MRCP2-3875

A 35-year-old woman with Alport’s syndrome underwent a living related renal transplant from her sister. She had good initial graft function and a baseline Creatinine of 98 µmol/l. However, six months later, she presented with a 2-week history of reduced urine output and an elevated creatinine level of 210 µmol/l.

Despite a biopsy that showed no signs of acute rejection, urine microscopy revealed dysmorphic red blood cells. She gradually became oligo-anuric and required dialysis.

What is the probable diagnosis in this case?

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?

MRCP2-3887

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?

MRCP2-3884

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?

MRCP2-3883

A 50-year-old woman with a history of type I diabetes and a recent renal transplant some three months earlier presents to the Emergency Department with a rise in her creatinine level of > 30% of post-transplant baseline. She has been taking cyclosporin since her transplant and has recently started new medication for paroxysmal atrial fibrillation (AF). You suspect a drug interaction. On examination, her blood pressure is 142/70 mmHg, and pulse 70 bpm (regular). Which of the following medications is most likely responsible for the rise in creatinine level?

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?