Archives: MRCP Part 2

MRCP2-3824

A 56-year-old Caucasian man with a history of type 2 diabetes mellitus presents to his primary care physician complaining of worsening pedal edema. Upon further inquiry, he reveals experiencing weight loss and changes in bowel habits over the past six months.

During the examination, the patient appears disheveled, and there is pitting edema in both thighs and sacral regions. His lungs are clear, and his cardiac examination is unremarkable, with no elevated JVP. Abdominal and digital rectal examinations are normal. A urine dip reveals protein +++ but is otherwise negative.

The patient’s lab results show Hb 78 g/l, Na+ 135 mmol/l, Bilirubin 20 µmol/l, Platelets 340 * 109/l, K+ 3.7 mmol/l, ALP 14 u/l, WBC 12 * 109/l, Urea 6 mmol/l, ALT 80 u/l, Neuts 3 * 109/l, Creatinine 67 µmol/l, gamma#GT 30 u/l, Lymphs 7 * 109/l, Albumin 18 g/l, and Eosin 0.1 * 109/l, MCV 82 fl.

What is the most likely diagnosis?

MRCP2-3825

A man with a history of sensorineural deafness and kidney problems is referred to the nephrology clinic. He has been diagnosed with Alport syndrome, which runs in his family. Recently, his partner gave birth to a baby boy. What is the probability that his son will inherit the condition, assuming the most common mode of inheritance?

MRCP2-3826

A 20 year-old man presents with frank haematuria. He had recently recovered from a severe cold and reports that the cold symptoms have now subsided. He only took paracetamol for the cold and did not receive any antibiotics. The patient has a history of hearing problems since childhood and currently wears hearing aids. He also had a corneal ulcer recently. Upon examination, his vital signs are stable and a urine dipstick test shows protein ++ and blood +++ in his urine.

The medical team decides to perform a renal biopsy. What is the most probable finding that will be observed under light microscopy?

MRCP2-3827

A 67-year-old man was admitted for an elective coronary angiogram. He had a past medical history of type 2 diabetes mellitus, hypertension and chronic kidney disease. His blood results are below:

Na+ 140 mmol/L (135 – 145)
K+ 5.1 mmol/L (3.5 – 5.0)
Bicarbonate 21 mmol/L (22 – 29)
Urea 11.8 mmol/L (2.0 – 7.0)
Creatinine 194 µmol/L (55 – 120)

What is the most effective measure to prevent contrast-induced nephropathy in this patient?

MRCP2-3829

A 70-year-old woman with a history of multiple myeloma is undergoing investigation for bilateral carpal tunnel syndrome, worsening shortness of breath, and edema. Based on her test results, which are as follows:

– Hemoglobin: 105 g/L
– Platelets: 145 * 10^9/L
– White blood cells: 7.2 * 10^9/L
– Calcium: 2.70 mmol/L
– Urea: 4.3 mmol/L
– Creatinine: 150 µmol/L
– Urine protein: >3.5 g/day

Her chest x-ray reveals cardiomegaly with fluid overload. What is the most likely cause of her symptoms?

MRCP2-3830

A 29-year-old male presents to the endocrinology outpatient clinic with a 2-month history of weight loss, palpitations, and increasing anxiety. His GP suspects hyperthyroidism and has referred him for further evaluation. The patient has no significant medical history except for a right orchidopexy at the age of 11 and a fibula fracture sustained while playing football at the age of 13. On examination, he appears anxious with bilateral sweaty palms. His BMI is 13.8 kg/m², and a systolic murmur is heard with a sinus tachycardia of 120 beats per minute. No neck swelling is observed or palpated.

The patient’s blood tests reveal a Hb of 147 g/l, platelets of 278 * 109/l, WBC of 8.9 * 109/l, Na+ of 141 mmol/l, K+ of 3.8 mmol/l, urea of 4.5 mmol/l, TSH of < 0.01 mu/l, free T4 of 33.3 pmol/l (normal 10-24), and beta HCG of 16000 (normal range < 5 mIU/ml for men). What is the most appropriate next investigation?

MRCP2-3831

You are seeing an 80 year old man in renal outpatient clinic with known CKD4. He is feeling much better than he did last time he saw you in clinic and only occasionally feels slightly tired, a problem which is only occasionally limiting. You saw him three months ago with similar problems and had started him on iron replacement therapy (ferrous fumarate 210mg three times daily). His bloods at clinic three months ago and today are shown below:

Three months ago:

Hb 77 g/l
Platelets 178 * 109/l
WBC 3.2 * 109/l
MCV 71 fl
Ferritin 78 ng/ml
Transferrin saturations 12%
B12 451 pg/ml
Folate 4.8 nmol/nl
TSH 2.1 mIU/L

Today:

Hb 101 g/l
Platelets 172 * 109/l
WBC 4.5 * 109/l
MCV 78 fl
Ferritin 621 ng/ml
Transferrin saturations 21%
B12 721 pg/ml
Folate 3.8 nmol/nl
TSH 2 mIU/L

What is your next course of action?

MRCP2-3832

A 65-year-old gentleman with a history of polycystic kidneys and undergoing haemodialysis for the last six months presented to the renal patient clinic with complaints of increasing shortness of breath on exertion and reduced appetite. His GP had previously conducted investigations and prescribed ferrous sulphate, but the patient did not feel much better. On examination, he appeared pale with a blood pressure of 132/78 mmHg, heart rate of 82 bpm, and respiratory rate of 18/min. Two ballotable masses were noted in the renal angle. Further investigations revealed elevated levels of urea and creatinine. What is the most appropriate next step in management?

MRCP2-3833

A 70-year-old man presents with sudden onset shortness of breath and haemoptysis, with oxygen saturations of 92% on room air. His general practitioner had prescribed furosemide 40mg once a day two days prior to admission for progressive lower limb swelling and fatigue. He was scheduled to see his general practitioner tomorrow to review the initial blood tests. He has a medical history of systemic hypertension and stage 2 colon cancer treated with surgical resection and adjuvant chemotherapy 15 years ago. He is a current smoker.

What is the next step in management given the following results from a full panel of bloods, including a full vasculitic screen?

White cells 12.0 × 10^9/l
Haemoglobin 11.7 g/dl
Sodium 144 mmol/l
Potassium 5.6 mmol/l
Urea 18 mmol/l
Creatinine 240 mol/l
Albumin 19 g/l
ANA negative
ANCA negative
Anti-GBM positive

Additionally, an arterial blood gas shows a type 1 respiratory failure, with a pH of 7.31 and a pO2 of 9.7 kPa. Oxygen saturations of >96% are achieved with four litres of oxygen. A chest x-ray shows alveolar infiltrates within the right lower lobe. Urgent spirometry reveals an increased transfer factor. Urine dip demonstrates a loss of protein, but no blood, leucocytes or nitrites.

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?