Archives: MRCP Part 2

MRCP2-3849

A 50-year-old man presents with severe left loin pain that radiates to his groin in spasms. He has a history of Crohn’s disease and had a small bowel resection with a jejunocolic anastomosis. Despite being on steroids, his Crohn’s disease has been quiescent for the past year. He has a normal bowel habit and eats a high-fiber diet while drinking 3 liters of fluid per day. On examination, he is tender in the left loin and has a blood pressure of 180/70 mmHg. Urinalysis shows +++ blood with no protein or nitrates and a urine pH of 5.5. A plain KUB x-ray reveals a radio-opaque area over the left ureter, and an IVU confirms the presence of a small calculi. What is the most likely cause of his renal stone?

MRCP2-3850

A 57-year-old woman is admitted to the ward with symptoms of sore throat, joint pains, shivering attacks, and rash. She has been taking lithium for bipolar disorder for the past two years. Her blood tests show low haemoglobin, high white cell count, high platelets, high urea, high creatinine, and eosinophils and red blood cells in her urine. What is the most probable diagnosis?

MRCP2-3851

A 70-year-old man with hypertension and type II diabetes mellitus managed with insulin on a basal-bolus regimen is admitted to the hospital with an acute, right-sided middle cerebral artery stroke. He is not thrombolysed due to hypertension and is transferred to the Stroke Ward for long-term management and rehabilitation. What is the probable underlying diagnosis based on his medical history and investigations?

MRCP2-3852

A 26-year-old woman has been referred to your renal outpatient clinic by her general practitioner due to complaints of tiredness. She is not currently taking any medications. During examination, her blood pressure was measured at 180/95 mmHg. Routine investigations by her general practitioner showed normal levels of serum sodium and urea, but low levels of serum potassium and slightly elevated levels of serum creatinine. She was admitted to the hospital for further investigations, which revealed a plasma renin activity of 5.2 pmol/ml/h (1.1-2.7) and a serum aldosterone level of 900 pmol/L (135-400). What is the correct diagnosis?

MRCP2-3853

A 65-year-old woman presented to the rheumatology clinic for follow-up of her rheumatoid arthritis. Upon examination, she displayed symptoms and signs of active synovitis with elevated inflammatory markers. She had been receiving IM sodium aurothiomalate 50 mg once a week for the past six months and had recently completed a course of diclofenac 50 mg three times a day. Laboratory tests revealed a serum sodium level of 138 mmol/L (137-144), serum potassium level of 4.9 mmol/L (3.5-4.9), serum urea level of 12 mmol/L (2.5-7.5), and serum creatinine level of 290 µmol/L (60-110). A urine dipstick test showed protein and blood levels of ++, while a 24-hour urine collection revealed a protein level of 0.4 g/24hr (<0.2). Her renal function had been normal during her last clinic visit two months prior. What is the most likely cause of the decline in renal function?

MRCP2-3819

A 67-year-old man presents to the emergency department complaining of pain in his right forearm. He has a medical history of hypertension and end-stage renal failure and is currently taking ramipril, amlodipine, and doxazosin.

Upon examination, an arteriovenous fistula is observed in the right forearm, with an audible bruit. No other swelling or erythema is present, and there is no pain when the forearm is moved passively. The hand’s color appears normal.

What is the probable diagnosis?

MRCP2-3820

A 70-year-old man is rushed into emergency surgery for an abdominal aortic aneurysm repair. You are called to assess him three days later in the surgical high-dependency unit. Upon examination, he appears drowsy but has a Glasgow coma scale of 15/15. His blood pressure is 150/90 mmHg, and his central venous pressure recording (CVP) is +14 cm H2O.

Further investigations reveal the following results:
– Serum sodium: 132 mmol/L (137-144)
– Serum potassium: 5.9 mmol/L (3.5-4.9)
– Serum urea: 32.8 mmol/L (2.5-7.5)
– Serum creatinine: 520 µmol/L (60-110)
– Urinary sodium: 58 mmol/L
– Urine volume: 320 ml/24 hr
– Urine osmolality: 280 mOsmol/L

An ultrasound scan shows that the left kidney measures 12.7 cm in length, and the right kidney measures 11.5 cm in length.

What clinical finding would suggest a diagnosis of acute tubular necrosis (ATN) rather than pre-renal failure?

MRCP2-3821

A 15-year-old boy presents with headache, nausea, and vomiting. He had been healthy prior to the onset of symptoms, which worsened over the past 12 hours. Upon admission, he appears slightly confused, has a temperature of 39 degrees Celsius, and exhibits a positive Kernig’s sign and a faint purpuric rash on his knees. His blood pressure is 90/60 mmHg, and his pulse is 120 beats per minute. A CT head scan and lumbar puncture confirm a diagnosis of meningococcal meningitis, and he is admitted to the intensive care unit and treated with IV cefotaxime 2 g tds and benzylpenicillin 2.4 g qds. His admission is complicated, requiring intubation, ventilation, and hypotensive episodes. On the second day of his admission, his urine output decreases, with an hourly output of approximately 10 ml/hr.

Further investigations reveal:
– Haemoglobin: 167 g/L (115-165)
– White cell count: 16.8 ×109/L (4-11)
– Platelets: 100 ×109/L (150-400)
– Serum sodium: 125 mmol/L (137-144)
– Serum potassium: 5 mmol/L (3.5-4.9)
– Serum urea: 6.7 mmol/L (2.5-7.5)
– Serum creatinine: 100 µmol/L (60-110)
– Plasma osmolality: 300 mosmol/Kg (278-305)
– Urine osmolality: 285 mosmol/Kg (350-1000)
– Urine urea: 120 mmol/L
– Urine sodium: 75 mmol/L

Why is this case indicative of acute tubular necrosis rather than pre-renal failure?

MRCP2-3822

A 55-year-old man presents to the emergency department with complaints of nausea and lethargy two weeks after starting omeprazole for gastro-oesophageal reflux. His blood work reveals a hemoglobin level of 121 g/L (130-180), elevated eosinophils at 0.52 ×109/L (0.04-0.4), high creatinine levels at 395 μmol/L (60-110), and low bicarbonate levels at 20 mmol/L (20-28). Additionally, his urinalysis shows +++ blood, +++ leucocytes, and + protein. What is the most likely diagnosis?

MRCP2-3834

A 65-year-old woman presented to the hospital with haematuria and other symptoms. She had been feeling unwell for a few weeks with vomiting, weight loss, fevers, and lethargy. The day before admission, she experienced haematuria with reduced urine output. She had no prior medical history but was an ex-smoker and worked as a retail shop manager. On examination, she appeared pale and lethargic with mild peripheral oedema. Her chest was clear, and her abdomen was soft and non-tender with no palpable masses.

The following investigations were conducted:

– Urine dip: blood+++, protein++
– Haemoglobin: 86 g/L
– White cell count: 8.7 x10^9/L
– Platelet Count: 201×10^9/L
– INR: 1.0
– Serum sodium: 139 mmol/L
– Serum potassium: 6.3mmol/L
– Serum urea: 34.0mmol/L
– Serum creatinine: 789 micromol/L
– CRP: 32
– Antinuclear antibody: negative
– Anti-neutrophil cytoplasmic antibody: negative
– Anti-glomerular basement membrane antibody: positive

Based on the results, she was diagnosed with renal limited anti-GBM disease and started on methylprednisolone and cyclophosphamide. What other treatment options should be considered?