Genitourinary COPY Flashcards

Question

Describe the management for prostate cancer (local and metastatic). How hormone sensitive is it?

Answer 1

- If local: PROSTATECTOMY (\<70), ACTIVE SURVEILLANCE (\>70 and low risk), RADIOTHERAPY - If metastatic: CHEMOTHERAPY, RADIOTHERAPY, BILATERAL ORCHIECTOMY (gold standard hormonal treatment), Goserelin (suppresses testosterone production as testosterone stimulates growth of prostate cancer), palliative treatments focusing on relieving symptoms, e.g. TURP - It is the most hormone sensitive malignancy

Answer 2

- Testicular cancer arises from the germ cells in the testes. Germ cells are cells that produce gametes (sperm in males). There are other, rare tumours in the testes, e.g. non-germ cell tumours and secondary metastases - Most common solid tumour in men aged 20-45 - Good survival rate (98% 5 year survival) - Two types: - Seminomas - Non-seminomas (most teratomas)

Answer 3

- Age 20-45 - Caucasian - Cryptorchidism - Previous testicular cancer - HIV - Family history

Answer 4

- PALPABLE LUMP WITHIN THE TESTIS - non-transilluminable (light can’t get through tumour), may be painful/painless - Gynaecomastia (especially Leydig cell tumour) - Haematospermia

Answer 5

- SCROTAL ULTRASOUND (urgent) is usually the initial investigation - CXR if symptomatic for pulmonary metastases - Tumour markers (not always raised, not always diagnostic, can be useful to check response before and after surgery) - alpha-fetoprotein, beta-hCG, LDH

Answer 6

Depending on the staging (Royal Marsden used): - URGENT RADICAL INGUINAL ORCHIECTOMY +/- a testicular prosthesis - this is for seminoma - CHEMOTHERAPY for non-seminoma (alpha-feto protein) - Semen cryopreservation - Treatment for metastatic disease - retroperitoneal lymph node dissection if tumour has metastasised to lymph nodes, chemotherapy, radiotherapy

Answer 7

- Bladder cancer = arises from the urothelium - Most common subtype is TRANSITIONAL CELL CARCINOMA of the bladder (90%) - Most common sites of metastasis = lymph nodes, bones, lung, liver

Answer 8

- Increasing age - Smoking - Male - Caucasian - Exposure to DYES/RUBBER/LEATHER/TEXTILES + PAINT - hairdresser, painter etc. (so question would be painter and painless visible haematuria) - Cyclophosphamide (RA/chemotherapy) + previous pelvic radiotherapy

Answer 9

- PAINLESS VISIBLE HAEMATURIA (can be non-visible too, one to remember for exams) - Urgency - Suprapubic/pelvic mass pain - Recurrent UTI - Symptoms of systemic spread - bone pain, weight loss etc.

Answer 10

- FLEXIBLE CYSTOSCOPY - Bloods - Urine sample for microscopy + culture - Ultrasound

Answer 11

- Psychosocial factors: cancer specialist nurse support, Macmillan support - Medical: radiotherapy, chemotherapy (intravesical therapy or systemic) + symptomatic relief - Surgical: TRANSURETHRAL RESECTION OF BLADDER TUMOUR (TURBT), radical cystectomy, cystodiathermy

Answer 12

- Most common type is RCC = malignant cancer of proximal convoluted tubule - Often asymptomatic and discovered incidentally - 25% have metastasis at presentation

Answer 13

Classical triad: - HAEMATURIA - Vague LOIN PAIN - PALPABLE mass in abdomen/lower back - May present with VARICOCELE - invasion of left renal vein leads to compression of left testicular vein

Answer 14

- USS (1st line) - CT chest/abdomen/pelvis (more sensitive than USS) - RENAL BIOPSY = diagnostic

Answer 15

Surgery to remove the tumour is first line: - PARTIAL NEPHRECTOMY = part of the kidney removed - RADICAL NEPHRECTOMY = entire kidney removed plus surrounding tissue

Answer 16

PARANEOPLASTIC CHANGES - polycythaemia, HTN, hypercalcaemia, Cushing's

Answer 17

- AWETBED: - Acid-base balance - Water removal - EPO - Toxins - BP - produces renin - Electrolyte balance, e.g. sodium, potassium - Vitamin D activation (Urea excretion as well)

Answer 18

- Nephron = basic unit of the kidney - Millions of nephrons in the cortex + medulla: - Renal corpuscle (glomerulus within Bowman's capsule) = filter - Proximal convoluted tubule = for reabsorbing solutes - Loop of Henle = for concentrating urine - Distal convoluted tubule = for reabsorbing more water and solutes - Collecting duct = for reabsorbing water + controlling acid-base + ion balance

Answer 19

- Cardiac output = 5L/min - Renal blood flow = 1L/min - Urine flow = 1ml/min

Answer 20

Renal artery --\> interlobar artery --\> arcuate artery --\> interlobular artery --\> afferent arteriole --\> (nephron) glomerular capillary and peritubular capillary

Answer 21

Passage of fluid from the blood into Bowman's space to form the filtrate

Answer 22

- Endothelium - fenestrated - Glomerular basement membrane - T4 collagen, -ve charge - Epithelium - podocytes with foot processes

Answer 23

- Small molecules + ions up to 10kDa can pass freely, e.g. glucose, uric acid, potassium, creatinine - Larger molecules increasingly restricted - Fixed negative charge in glomerular basement membrane repels negatively charged anions

Answer 24

- The volume of fluid filtered from the glomerulus to the Bowman's Space per unit time - GFR = Kf (Pgc - Pbs - Pi gc) - P is hydrostatic pressure, Pi is oncotic pressure - In a 70kg person the average GFR = 125ml/min

Answer 25

- Blood pressure = increase in BP --\> increased hydrostatic pressure --\> increase in GFR - Size of substance = albumin + all that is attached (lipophilic molecules) to it is unable to cross - Charge of substance = BM is negatively charged, repels other -vely charged substances, e.g. albumin - Attachment to protein = albumin - Capillary permeability - Surface area

Answer 26

- Use of a marker substance: free filtered (not attached to large proteins), not metabolised + not secreted/reabsorbed - Amount excreted per minute = amount filtered per minute - GFR = Um (concentration of marker substance in urine) x urine flow rate / Pm (concentration of marker substance in plasma) - Clinically: CREATININE (muscle metabolite) - GOLD STANDARD = INULIN

Answer 27

Creatinine

Answer 28

1. Not metabolised 2. Freely filtered 3. Not reabsorbed/secreted

Answer 29

Trimethoprim. Serum creatinine rises and so kidney function (GFR) appears worse

Answer 30

Decreased GFR

Answer 31

Increased GFR

Answer 32

- Volume of plasma from which a substance is completely removed by the kidney per unit time - Marker substance is freely filtered at the glomerulus + is neither reabsorbed nor secreted in the tubule, so all the marker substance that is filtered will end up in the urine, no more (as it is not secreted) and no less (as it is not reabsorbed) - Clearance = urine concentration x urine volume / plasma concentration

Answer 33

1. Sodium 2. Chlorine 3. Potassium 4. Glucose 5. Water 6. Amino acids 7. Bicarbonate

Answer 34

- 2 parts: descending and ascending - Descending: H2O reabsorption (impermeable to ions) - Ascending: Na+, K+ and Cl- reabsorption, has thin (simple squamous epithelium) + thick (low cuboidal) part - Found only on juxtamedullary (15%) nephrons, cortical (85%) nephrons do not extend into medulla

Answer 35

- Fine tuning, absorption of solutes - beginning to concentrate the urine. Acidified the urine by secreting H+ ions into it - Exchanges urinary Na+ for body K+, this effect is mediated by aldosterone - Macula densa = detects Na+ concentration. If low (indicator of low GFR) --\> sends signals to release renin --\> RAAS --\> increase in BP --\> increase GFR

Answer 36

- Acid secretion and concentration of urine, hormones such as aldosterone and ADH act here - 2 cells: - Principal cells (respond to aldosterone = exchanging Na+ for K+ and ADH = increasing water reabsorption) - Intercalated cells (responsible for exchanging acid for base). Alpha intercalated cells secrete acid, beta intercalated cells secrete bicarbonate

Answer 37

- Nephrolithiasis = kidney stones. They are hard stones that form in the renal pelvis, where the urine collects before travelling down the ureters - Slightly more common in men (testosterone -\> increased oxolate) - Stones form when solutes precipitate out as crystals in urine

Answer 38

- Calcium stones: - CALCIUM OXOLATE (more common) (80%) - Calcium phosphate - Other types of kidney stones include: - Uric acid – these are not visible on x-ray - Struvite – produced by bacteria, so associated with infection - Cystine – associated with cystinuria, an autosomal recessive disease

Answer 39

- Raised serum calcium (hypercalcaemia, hyperparathyroidism) - Reduced urine output (chronic dehydration, high protein/salt diet) - Recurrent UTIs - Congenital abnormalities

Answer 40

- OBSTRUCTION leading to acute kidney injury - INFECTION with obstructive pyelonephritis

Answer 41

- RENAL COLIC. This UNILATERAL LOIN TO GROIN PAIN that can be excruciating (“worse than childbirth”) and COLICKY (fluctuating in severity) as the stone moves and settles - Restlessness - N+V - Haematuria - Dysuria

Answer 42

- Urine dipstick usually shows HAEMATURIA - Bloods: FBC, CRP, U+Es - check for hypercalcaemia and infection - GOLD STANDARD = NON-CONTRAST CT of the kidneys, ureters and bladder (KUB) - Abdominal X-ray will show calcium stones but not uric acid stones (radiolucent) - Ultrasound KUB is less preferred

Answer 43

- NSAIDs = most effective analgesia, e.g. IM diclofenac - Antiemetics for N+V, antibiotics if infection - Watchful waiting for stones \<5mm as they usually pass - tamsulosin (alpha-blocker) can help with this - If do not pass, \>10mm, or complete obstruction or infection = SURGERY: - ESWL (Extracorporeal shock wave lithotripsy) = break stone into smaller fragments using shockwaves - Uteroscopy - PCNL (percutaneous nephrolithotomy) = nephroscope inserted to remove stone - Lifestyle: decrease sodium and protein intake, increased citrus fruit, adequate fluid intake

Answer 44

- Abnormal kidney function present for \>3 MONTHS - Aetiology: - Diabetes - Hypertension - Age-related decline - Glomerulonephritis - Polycystic kidney disease - Medications such as NSAIDS, proton pump inhibitors and lithium

Answer 45

- Older age - Hypertension - Diabetes - Smoking - Use of medications that affect the kidneys, e.g. NSAIDS

Answer 46

- Usually CKD is ASYMPTOMATIC and diagnosed upon testing. Signs and symptoms usually due to uraemia: - Pruritus - Nausea - Reduced appetite - Oedema

Answer 47

- Bloods: U+E to check the ESTIMATED GLOMERULAR FILTRATION RATE (eGFR): - G1 = \>90 mL/min/1.73m^2 - G2 = 60-89 mL/min/1.73m^2 (\<60 = CKD) - G3a = 45-59 mL/min/1.73m^2 - G3b = 30-44 mL/min/1.73m^2 - G4 = 15-29 mL/min/1.73m^2 - G5 = \<15 mL/min/1.73m^2 = end-stage renal failure - Urinalysis: - Proteinuria can be checked using urine albumin:creatinine ratio - Haematuria can be checked using a urine dipstick - Renal ultrasound

Answer 48

- Anaemia - Renal bone disease - Cardiovascular disease - Peripheral neuropathy - Dialysis related problems

Answer 49

- ACE inhibitors are FIRST LINE - CKD is irreversible in many: - Slowing the progression of the disease: optimise diabetic control, optimise hypertensive control, treat glomerulonephritis - Reducing the risk of complications: exercise, maintain a healthy weight and stop smoking, special dietary advice about phosphate, sodium, potassium and water intake, offer atorvastatin 20mg for primary prevention of cardiovascular disease - Treating complications: ORAL SODIUM BICARBONATE to treat metabolic acidosis, IRON supplementation and EPO to treat anaemia, vitamin D to treat renal bone disease, dialysis in end stage renal failure, renal transplant in end stage renal failure

Answer 50

- Considered for patients with: END STAGE RENAL FAILURE (eGFR\< 15 = stage 5), acidosis not responsive to bicarb, persistent electrolyte disturbances, persistent oedema, severe symptoms of uraemia (seizures, LOC) - RRT = therapy that replaces the normal blood-filtering function of the kidney: - Haemodialysis - most common - Peritoneal dialysis - Renal transplant

Answer 51

B) mL/min/1.73m^2

Answer 52

Acute kidney injury (AKI) is defined as an acute drop in kidney function. It is diagnosed by measuring the serum CREATININE +/- decreased urine output. Results in IMBALANCE IN ELECTROLYTES and azotaemia (increased creatinine/nitrates) = BAD

Answer 53

Creatinine is a waste product made by your muscles as part of everyday activity. Normally, your kidneys filter creatinine from your blood and send it out of the body in your urine. If there is a problem with your kidneys, creatinine can build up in the blood

Answer 54

- CKD - Diabetes - Hypertension - Older age (\> 65 years) - Nephrotoxic medications, e.g. NSAIDs, ACEi

Answer 55

- Pre-renal - Intra-renal - Post-renal

Answer 56

Pre-renal pathology is the MOST COMMON cause of acute kidney injury. It is due to inadequate blood supply to kidneys reducing the filtration of blood. Inadequate blood supply may be due to: - Dehydration - Hypotension (shock) - Heart failure (decreased volume = decreased perfusion = decreased GFR and decreased creatinine clearance = RAAS activation = increased Na+, urea + BP)

Answer 57

This is where INTRINSIC DISEASE in the kidney is leading to reduced filtration of blood. It may be due to: - Glomerulonephritis - barrier damage + protein leakage = decreased oncotic pressure = decreased GFR - Interstitial nephritis = inflammation and immune cells = - Acute tubular necrosis - Vasculitis

Answer 58

Post renal acute kidney injury is caused by OBSTRUCTION TO THE OUTFLOW of urine from the kidney, causing back-pressure into the kidney and reduced kidney function. This is called an OBSTRUCTIVE UROPATHY. Obstruction may be caused by: - Kidney stones - Masses such as cancer in the abdomen or pelvis - Ureter or urethral strictures - Enlarged prostate or prostate cancer

Answer 59

- Universal: OLIGURIA (\<0.5 mL/kg/hr \>6hrs), HIGH CREATININE, hyperkalaemia, uraemia - Pre-renal: hypotension, signs of liver or heart failure (oedema) - Intra-renal: infection, signs of underlying disease - Post-renal: LUTS (BPH)

Answer 60

- URINALYSIS for protein, blood, leucocytes, nitrites and glucose: - Leucocytes and nitrites suggest infection - Protein and blood suggest acute nephritis (but can be positive in infection) - Glucose suggests diabetes - U+E - eGFR - CREATININE levels - a rise in serum creatinine of 26 micromol/L or greater within 48 hours - Ultrasound of the urinary tract is used to look for obstruction

Answer 61

- Rise in creatinine of ≥ 25 micromol/L in 48 hours - Rise in creatinine of ≥ 50% in 7 days - Urine output of \< 0.5ml/kg/hour for \> 6 hours

Answer 62

- First step = identify and treat underlying cause: ## Footnote - FLUID REHYDRATION with IV fluids in pre-renal AKI - STOP NEPHROTOXIC MEDICATIONS such as NSAIDS and antihypertensives that reduce the filtration pressure (i.e. ACE inhibitors) - RELIEVE OBSTRUCTION in a post-renal AKI, e.g. insert a catheter for a patient in retention from an enlarged prostate

Answer 63

- Hyperkalaemia - Fluid overload, heart failure and pulmonary oedema - Metabolic acidosis - Uraemia (high urea) can lead to ENCEPHALOPATHY or PERICARDITIS

Answer 64

- Pre-renal: hypotension - Intra-renal: glomerulonephritis - Post-renal: kidney stones

Answer 65

- CKD - Hypertension - Diabetes

Answer 66

- Pyelonephritis - infection of the kidneys - Urethritis – infection of the urethra - Cystitis – infection of the bladder - Prostatitis - infection of the prostate - Vaginitis – infection of the vagina

Answer 67

- Pyelonephritis refers to inflammation of the kidney resulting from bacterial infection. The inflammation affects the renal pelvis (join between kidney and ureter) and parenchyma (tissue) - Most commonly acquired via ASCENDING TRANSURETHRAL SPREAD but can be via blood or lymphatics

Answer 68

- Majority are caused by UPEC (gram negative, anaerobic, rod-shaped bacteria) - Other causes: - Klebsiella pneumoniae (gram-negative anaerobic rod) - Enterococcus - Pseudomonas aeruginosa - Staphylococcus saprophyticus - Candida albicans (fungal)

Answer 69

- Similar presentation to lower UTIs (i.e. dysuria, suprapubic discomfort and increased frequency) plus the ADDITIONAL TRIAD OF SYMPTOMS: - Fever, loin pain, N+V - Patients may also have: systemic illness, loss of appetite, haematuria, renal angle tenderness on examination

Answer 70

- 1st line = urine dipstick (will show signs of infection) - GOLD STANDARD - mid-stream urine for MC+S (microscopy, culture and sensitivity) - Blood tests will show raised WBCs + raised inflammatory markers, e.g CRP - Urgent USS to detect stones, obstruction or incomplete bladder emptying

Answer 71

Referall to hospital if there are features of sepsis (SEPSIS SIX (3 tests, 3 treatments): ## Footnote - Three tests: blood lactate level, blood culture, urine output - Three treatments: oxygen to maintain oxygen saturations of 94-98% (or 88-92% in COPD), empirical broad-spectrum IV antibiotics (according to local guidelines), IV fluids

Answer 72

- Urethral inflammation due to infectious or non-infectious cause - Infectious: gonococcal (NEISSERIA GONORRHOEA) or non-gonococcal (CHLAMYDIA TRACHOMATIS) - Non-infectious: trauma, chemical irritation

Answer 73

- Biologically male, young - Multiple sexual partners - Partner with a sexually transmitted disease (STD) - Unprotected sexual intercourse

Answer 74

- Skin lesion - Dysuria +/- discharge (blood/ pus) - Urethral pain - Penile discomfort/pruritus

Answer 75

- Nucleic acid amplification tests (NAAT) - Microscopy and culture of urethral discharge - Urine dipstick to exclude UTI - STI testing

Answer 76

Management of underlying cause - antibiotics, e.g. azithromycin and partner notification

Answer 77

Reactive arthritis - triad of conjuctivitis, urethritis and arthritis - 'can't see, can't pee, can't climb a tree'

Answer 78

- Cystitis is a chronic condition causing inflammation in the bladder - Women are more susceptible due to SHORTER URETHRA and SHORT PROXIMITY to anus which allows bacteria transfer - Causes: KEEPS: Klebsiella, E.coli (most common), Enterococci, Proteus species, Staph aureus/saprophyticus

Answer 79

- SUPRAPUBIC PAIN, worse with a full bladder and often relieved by emptying the bladder - FREQUENCY of urination - URGENCY of urination - Confusion (in elderly) - Dysuria

Answer 80

- 1st line = urine dipstick = increased leukocytes/blood/nitrates - Gold standard = MID-STREAM MC+S - Cystoscopy - for bladder cancer

Answer 81

- Antibiotics: TRIMETHOPRIM/NITROFURANTOIN (3 day course for women, 7 day for men/complicated women). In pregnancy = trimethoprim cannot be used in 1st trimester (inhibits folate synthesis), nitrofurantoin cannot be used in 3rd trimester - amoxicillin, cefalexin can both be used

Answer 82

- Prostatitis refers to inflammation of the prostate. It can be classed as: - Acute bacterial prostatitis – acute infection in the prostate, presenting with a more rapid onset of symptoms - Chronic prostatitis – symptoms lasting for at least 3 months

Answer 83

- Chronic prostatitis presents with at least 3 months of: pelvic pain, LUTS, sexual dysfunction, pain with bowel movements + tender and enlarged prostate - Acute prostatitis = more acute presentation of similar symptoms and systemic symptoms of infection, e.g. fever, myalgia

Answer 84

- Urine dipstick testing can confirm evidence of infection - Urine MC&S can identify the causative organism and the antibiotic sensitivities - Chlamydia and gonorrhoea NAAT testing on a first pass urine, if sexually transmitted infection is considered

Answer 85

- Acute: - Hospital admission for systemically unwell or septic patients - Oral antibiotics, typically for 2-4 weeks (e.g., ciprofloxacin, ofloxacin or trimethoprim) - Analgesia (paracetamol or NSAIDs) - Laxatives for pain during bowel movements - Chronic: - Alpha-blockers (e.g., tamsulosin) relax smooth muscle, with rapid improvement in symptoms - Analgesia (paracetamol or NSAIDs) - Psychological treatment, where indicated (e.g., cognitive behavioural therapy and / or antidepressants) - Antibiotics if less than 6 months of symptoms or a history of infection (e.g., trimethoprim or doxycycline for 4-6 weeks) - Laxatives for pain during bowel movements

Answer 86

- Uncomplicated UTI — UTI caused by typical pathogens in people with a normal urinary tract and kidney function, and no predisposing co-morbidities - Complicated UTI — UTI with an increased likelihood of complications such as persistent infection, treatment failure and recurrent infection

Answer 87

- Varicocele - Testicular torsion - Epididymal cyst - Epididymitis - Hydrocele

Answer 88

- A varicocele is the abnormal dilation of the internal spermatic veins and pampiniform plexus that drain blood from the testis - Left side more commonly affected (angle that left testicular vein enters the left renal vein = increased flow resistance)

Answer 89

Scrotal enlargement

Answer 90

Testicular damage = atrophy = poor sperm production + quality = infertility

Answer 91

- Feels like a BAG OF WORMS - Dragging/soreness/heaviness of the scrotum

Answer 92

- Clinical diagnosis - Doppler ultrasound - Semen analysis

Answer 93

Surgical repair if there is pain, infertility, or testicular atrophy

Answer 94

- Testicular torsion refers to twisting of the spermatic cord with rotation of the testicle - It is a urological emergency - delay in treatment increases the risk of ischaemia and necrosis of the testicle, leading to sub-fertility or infertility

Answer 95

- A BELL-CLAPPER DEFORMITY is one of the causes of testicular torsion Normally, the testicle is fixed posteriorly to the tunica vaginalis. A bell-clapper deformity is where the fixation between the testicle and the tunica vaginalis is absent. The testicle hangs in a horizontal position (like a bell-clapper) instead of the typical more vertical position. It is also able to rotate within the tunica vaginalis, twisting at the spermatic cord. As it rotates, it twists the vessels and cuts off the blood supply

Answer 96

- Sudden onset of acute, severe pain - Firm swollen testicle (on examination) - Elevated (retracted) testicle (on examination) - Absent cremasteric reflex (on examination) - Abnormal testicular lie - often horizontal (on examination)

Answer 97

UNNECESSARY IF CLINICAL FINDINGS ARE STRONGLY SUGGESTIVE: - Colour Doppler ultrasound - absent of decreased blood flow in affected testicle. Can show a whirlpool sign (spiral appearance to spermatic cord and blood vessels)

Answer 98

- SURGICAL DETORSION within 6 hours - Orchiopexy (correcting the position of the testicles and fixing them in place) - Orchidectomy (removing the testicle) if the surgery is delayed or there is necrosis

Answer 99

- Smooth extra testicular spherical cyst at the epididymis (top of the testicle) - Contains clear and milky fluid - TRANSLUMINATES (fluid-filled) - May be multiple and bilateral. When they get large can be painful. Can palpate the cyst and testis separately - No treatment is usually necessary

Answer 100

- Inflammation of the epididymis - Causes: - Infectious, e.g. E.coli, Chlamydia trachomatis - Non-infectious, e.g. trauma, autoimmune disease

Answer 101

- Usually unilateral scrotal pain, sometimes radiates to abdomen with/without swelling - Fever, chills - LUTS

Answer 102

- Gram stain of urethral secretions - Urine dipstick test, microscopy, and culture - Colour Doppler ultrasound - enlarged, thickened epididymis with increased blood flow = excludes testicular torsion

Answer 103

- Infectious epididymitis: ceftriaxone, doxycycline - Non-infectious: treat underlying cause

Answer 104

- A hydrocele is a collection of fluid within the tunica vaginalis that surrounds the testes: - Simple hydrocele: processus vaginalis is closed and more fluid is being produced by the tunica vaginalis (fluid trapped in the tunica vaginalis) than is being absorbed - Communicating hydrocele: the tunica vaginalis is connected with the peritoneal cavity via the processus vaginalis. This allows fluid to travel from the peritoneal cavity into the hydrocele, allowing the hydrocele to fluctuate in size

Answer 105

- Non-tender smooth cystic swelling - Painless unless infected - TRANSILLUMINATES with light

Answer 106

- Hydrocele - Partially descended testes - Inguinal hernia - Testicular torsion - Haematoma - Tumours (rare)

Answer 107

After clinical diagnosis, ULTRASOUND is useful for confirmation of diagnosis and excluding other causes

Answer 108

- Simple hydroceles = usually resolve within 2 years without having any lasting negative effects. They may require surgery if they are associated with other problems, such as a hernia - Communicating hydroceles = can be treated with a surgical operation to remove or ligate the connection between the peritoneal cavity and the hydrocele (the processus vaginalis)

Answer 109

- Uncomplicated UTI — UTI caused by typical pathogens in people with a normal urinary tract and kidney function, and no predisposing co-morbidities - Complicated UTI — UTI with an increased likelihood of complications such as persistent infection, treatment failure and recurrent infection

Answer 110

- Complicated = always send sample for culture - Uncomplicated = not necessary to send for culture, can treat empirically

Answer 111

Glomerulonephritis is an umbrella term applied to conditions that cause inflammation of or around the glomerulus and nephron. There are many conditions that can be described as glomerulonephritis, e.g. IgA nephropathy, minimal change disease, Goodpasture's syndrome

Answer 112

- The glomerulonephritides (glomerulonephritis) classically present on a spectrum ranging from nephrosis to nephritis - Nephritic syndrome refers to a group of symptoms, not a diagnosis. It simply means the patient does not fit a clinical picture of having inflammation of their kidney and it does not represent a specific diagnosis or give the underlying cause. Unlike nephrotic syndrome, there are no set criteria - Nephrotic syndrome refers to a group of symptoms without specifying the underlying cause. Therefore, nephrotic syndrome is not a disease, but is a way of saying “the patient has these symptoms”, which indicates there is an underlying disease present but doesn’t specify the disease.

Answer 113

- Renal: IgA nephropathy (Berger's disease) - Systemic - Post-streptococcal glomerulonephritis - Goodpasture's syndrome - SLE nephropathy - Small vessel vasculitis

Answer 114

- HAEMATURIA means blood in the urine. This can be microscopic (not visible) or macroscopic (visible) - OLIGURIA - PROTEINURIA. In nephritic syndrome, there is less than 3g / 24 hours. Any more and it starts being classified as nephrotic syndrome - FLUID RETENTION

Answer 115

- IgA nephropathy (Berger's disease) is where abnormal IgA forms -\> deposits in kidneys -\> kidney damage - COMMONEST cause of PRIMARY glomerulonephritis (not caused by another disease) worldwide

Answer 116

- Haematuria - Proteinuria usually \<1g

Answer 117

Renal biopsy (diagnostic) - histology shows 'IgA deposits and glomerular MESANGIAL proliferation'

Answer 118

- ACEi/ARB to reduce proteinuria - Corticosteroids if persistent proteinuria

Answer 119

- Systemic variant of IgA nephropathy with IgA deposition in the skin/joints/gut in addition to the kidney - Presentation = purpuric rash (typically on the legs) - Investigations and management are the same as IgA nephropathy

Answer 120

- Occurs 3-6 weeks after a streptococcal infection. Streptococcal antigen deposits in the glomerulus leading to immune complex formation and inflammation - Presentation: varies from HAEMATURIA to acute nephritis (haematuria, oedema, oliguria)

Answer 121

- Investigations: urinalysis - qualitative haematuria, proteinuria and evidence of STREP infection - Treatment: ACEi/ARB to reduce proteinuria, penicillins

Answer 122

- Anti-GBM (glomerular basement membrane) antibodies attack glomerulus and pulmonary basement membranes. This causes glomerulonephritis and pulmonary haemorrhage - In exam, there may be a patient that presents with acute kidney failure and haemoptysis (coughing up blood) - Presentation: SOB and OLIGURIA

Answer 123

- Investigations: renal biopsy and anti-GBM antibodies - Treatment: plasma exchange, corticosteroids and cyclophosphamide

Answer 124

- SLE nephropathy is inflammation of the kidneys caused by SLE - It can progress to end-stage renal failure

Answer 125

- Urine protein:creatinine ratio - Renal biopsy - Urinalysis = nephritic picture

Answer 126

- Prednisolone to reduce proteinuria - Monoclonal antibodies

Answer 127

- Diffuse proliferative glomerulonephritis, a histopathologic classification of glomerulonephritis commonly associated with autoimmune diseases, is characterized by an increased cellular proliferation affecting \> 50% of the glomeruli - Caused by IgA nephropathy, Henoch-Schonlein purpura, lupus nephritis etc. - Renal biopsy: LM = hypercellularity of endothelial and mesangial cells, IM = granular deposition of Ig, complement, and fibrin along the GBM, EM = electron-dense deposits - Treat underlying disease

Answer 128

- PERIPHERAL OEDEMA from hypoalbuminaemia - PROTEINURIA more than 3g/24 hours - HYPOALBUMINAEMIA - SERUM ALBUMIN less than 25g/L - HYPERCHOLESTERAEMIA

Answer 129

- Nephrotic syndrome occurs when the basement membrane in the glomerulus has podocyte damage, making it highly permeable to proteins: - Inflammation - from immune cells, HTN etc. - This causes DAMAGE to PODOCYTES = protein leakage (albumin) - Increased liver activity to increase albumin. Consequential increase in cholesterol + coagulation factors - Reduced oncotic pressure - oedema. Consequential blood volume decreases, RAAS stimulation, exacerbation

Answer 130

- Minimal change disease - Focal segmental glomerulosclerosis - Membranous nephropathy - Membranoproliferative glomerulonephritis

Answer 131

- DDANI: - Diabetic nephropathy - Drugs - Autoimmune - Neoplasia - Infection

Answer 132

- FROTHY URINE (from proteinuria) - OEDEMA (from hypoalbuminaemia) - Pallor

Answer 133

- GOLD STANDARD = needle biopsy and microscopy - light microscopy (LM), fluorescence microscopy (FM) and electron microscopy (EM) - General: - Bloods: U+E, FBC, LFT, CRP, Ca2+, glucose - MSU - Dipstick - USS kidney

Answer 134

- Treatment of underlying cause - 12 WEEKS CORTICOSTEROIDS - PREDNISOLONE - Treatment of complications: - Oedema (LOW SALT INTAKE/LOW PROTEIN DIET) - Hyperlipidaemia (STATINS if prolonged) - Hypercoagulable state (PROPHYLACTIC ANTICOAGULANTS - apixaban, LMWH (immediate effect), warfarin (delayed effect) - Infection (ABx)

Answer 135

- HYPERLIPIDAEMIA - loss of albumin increases cholesterol formation. Manage with statins - VTE - due to increased clotted factors. Give heparin

Answer 136

- Most common cause of nephrotic syndrome in CHILDREN - Mainly idiopathic - Needle biopsy = NO CHANGE on LM/FM. EM = loss of podocytes (effacement) - PREDNISOLONE

Answer 137

- COMMONEST glomerunephritis seen on renal biopsy. Adults - Causes = idiopathic or HIV, heroin, lithium, lymphoma - Needle biopsy: LM = SCLEROSIS (plaques), FM = nothing, EM = GBM thickening - ACEi/ARBs, corticosteroids only in idiopathic disease

Answer 138

- 25% of adult nephrotic syndrome - Primary (idiopathic) or secondary to malignancy, infection (e.g. hepatitis), immunological disease (SLE, RA), drugs - ANTI-PHOSPHOLIPASE A2 RECEPTOR in 70-80% of idiopathic disease. Diffusely thickened GBM due to subendothelial deposits. 'Spikes' on silver stain - ACEi/ARBs in all. Immunosuppression (corticosteroids + cyclophosphamide) only in those at high risk of progression

Answer 139

- 10% of adult nephrotic syndrome - Divided into immune-complex associated (e.g. infection) and C3 glomerulonephropathy - Needle biopsy: LM = mesangial expansion, capillary wall thickening, FM = IgG and COMPLEMENT 3 (C3) staining (granular appearance), EM = GBM thickening - ACEi/ARBs in all, underlying cause in immune-complex disease

Answer 140

Needle biopsy and microscopy

Answer 141

- Nephritic = proteinuria \<3g/24hrs, haematuria, hypertension, oliguria - Nephrotic = proteinuria \>3g/24hrs, hypoalabuminaemia, oedema, hypercholesteraemia

Answer 142

- Polycystic kidney disease is a genetic condition where the kidneys develop clusters of fluid-filled cysts - AUTOSOMAL DOMINANT: PKD1 (85%) and PKD2 (polycystin) genes - chromosome 16 - AUTOSOMAL RECESSIVE: caused by mutation on PKHD1 gene on chromosome 6 that codes for fibrocystin. Younger patients - usually found on antenatal screening

Answer 143

- Cysts develop and grow over time in the tubular portion of the nephron - Compression of renal architecture and vasculature - Progressive impairment - gets bigger and worse with age

Answer 144

- Autosomal recessive: OLIGOHYDRAMNIOS (lack of amniotic fluid) and polycystic kidneys on antenatal scans. Lack of amniotic fluid leads to POTTER'S SYNDROME - Autosomal dominant: HYPERTENSION, abdo/flank pain (haemmorrhage), headaches, LUTS

Answer 145

Renal USS and then renal biopsy for genes: - \<30yrs - at least 2 unilateral or bilateral cysts - 30-59yrs - 2 cysts in each kidney - \>60yrs - 4 cysts in each kidney

Answer 146

- TOLVAPTAN can slow the development of cysts and the progression of renal failure in autosomal dominant polycystic kidney disease. Recommended in certain situations - Antihypertensives for hypertension - Infected - Abx or drain - Surgical removal - nephrectomy - Chronic - dialysis (first-line renal replacement therapy) or transplant

Answer 147

- Associated with BERRY ANEURYSMS - rupture causing a SUB-ARACHNOID HAEMORRHAGE - Cysts on other organs, e.g. ovaries - 50% have ventricular hypertrophy - Pre-malignant

Answer 148

- Genetic disorder - mutation of tumour suppressor gene VHL (chr 3). Benign tumours and cysts in many organs, as well as malignant tumours in certain locations - Autosomal dominant, 20% de novo mutation

Answer 149

VHL normally regulates hypoxia inducible factor (HIF). HIF promotes transcription of PDGF and VEGF

Answer 150

Tumour locations: - CNS (haemangioblastoma) - Liver - Lungs - Pancreas (malignant neuroendocrine) - Adrenals (phaeochromocytoma) - Clear renal cell carcinoma (malignant) in 70% of people with VHL mutation - bilateral, multifocal tumours

Answer 151

- Renal cell carcinoma - haematuria, flank pain, abdominal mass (advanced stage typically) - B SYMPTOMS - weight loss, fever, fatigue, night sweats & disturbed sleep - CNS - ataxia, headaches, nausea & vomiting - Phaeochromo. - headaches, sweating, palpitations, HTN

Answer 152

- Screening - annual BP and abdominal USS (1st line) - CT head, chest and abdo - MRI – baseline scan; tumour staging - Bloods – FBC, U&Es, LFTs - Renal biopsy – histology of tumour (diagnostic)

Answer 153

Surgical excision once renal cell carcinoma \> 3cm. Usually asymptomatic prior to this and numerous small tumours and cysts may be present. Partial/radical nephrectomy (1st line)

Answer 154

- Chlamydia trachomatis is a gram-negative bacteria. Chlamydia is the most common sexually transmitted infection in the UK and a significant cause of infertility - Being young, sexually active and having multiple partners increase the risk of catching the infection. 50% of men and 75% of woman are aysmptomatic, though they can still pass the infection on

Answer 155

- Women: abnormal vaginal discharge, pelvic pain, abnormal vaginal bleeding (intermenstrual or postcoital), painful sex (dyspareunia), painful urination (dysuria) - Men: urethral discharge or discomfort, painful urination (dysuria), epididymo-orchitis, reactive arthritis

Answer 156

NUCLEIC ACID AMPLIFICATION TESTS (NAAT). This can involve a vulvovaginal swab, endocervical swab, first-catch urine sample (in women or men), urethral swab in men etc.

Answer 157

1st line for uncomplicated chlamydia is DOXYCYCLINE 100MG TWICE A DAY FOR 7 DAYS

Answer 158

- Pelvic inflammatory disease - Chronic pelvic pain - Infertility - Ectopic pregnancy - Epididymo-orchitis - Conjunctivitis

Answer 159

Neisseria gonorrhoeae is a Gram-negative diplococcus bacteria. It infects mucous membranes with a columnar epithelium, such as the endocervix in women, urethra, rectum, conjunctiva and pharynx. It spreads via contact with mucous secretions from infected areas

Answer 160

- Women (50% are symptomatic): - Odourless purulent discharge, possibly green or yellow - Dysuria - Pelvic pain - Men (90% are symptomatic): - Odourless purulent discharge, possibly green or yellow - Dysuria - Epididymo-orchitis

Answer 161

- NATT is used to detect the RNA or DNA of gonorrhoea, but no specific information - endocervical, vulvovaginal or urethral swabs, or in a first-catch urine sample - A standard charcoal endocervical swab should be taken for microscopy, culture and antibiotic sensitivities before initiating antibiotics - important due to high rates of antibiotic resistance and to idenitfy the specific bacteria

Answer 162

- A single dose of INTRAMUSCULAR CEFTRIAXONE 1g if the sensitivities are NOT known - A single dose of ORAL CIPROFLOXACIN 500mg if the sensitivities ARE known

Answer 163

- Pelvic inflammatory disease - Chronic pelvic pain - Infertility - Epididymo-orchitis (men) - Prostatitis (men) - GONOCOCCAL CONJUNCTIVITIS in neonates - medical emergency associated with sepsis, perforation of the eye and blindness

Answer 164

- Syphilis is caused by bacteria called Treponema pallidum - Stages: - Primary syphilis = PAINLESS ULCER at site of infection - Secondary syphilis = systemic symptoms - Latent syphilis = symptoms disappear - Tertiary syphilis = many years after initial infection - Neurosyphilis = occurs if the infection involves the central nervous system, presenting with neurological symptoms

Answer 165

- Primary syphilis = painless genital ulcer (chancre) - Secondary syphilis typically starts after the chancre has healed, with symptoms of: maculopapular rash, CONDYLOMATA LATA (grey wart-like lesions around the genitals and anus), low-grade fever - Tertiary syphilis can present with several symptoms depending on the affected organs: GUMMATOUS LESIONS (GUMMAS are granulomatous lesions that can affect the skin, organs and bones), aortic aneurysms, neurosyphilis - Neurosyphilis can occur at any stage if the infection reaches the CNS and present with symptoms of: headache, altered behaviour, dementia, TABES DORSALIS (demyelination affecting the spinal cord posterior columns), OCULAR SYPHILIS, ARGYLL-ROBERTSON PUPIL

Answer 166

ANTIBODY TESTING for antibodies to T.pallidum - DARK FIELD MICROSCOPY and POLYMERASE CHAIN REACTION (PCR)

Answer 167

- A single DEEP INTRAMUSCULAR dose of BENZATHINE BENZYLPENICILLIN. Alternative regimes and types of penicillin are used in different scenarios - All patients should be managed and followed up by specialist service, such as GUM. As with all other STIs, patients need: full screening for STIs, advice about avoiding sexual activity until treated, contact tracing, prevention of future infections

Answer 168

- Pelvic inflammatory disease is inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix - Causes: STIs, e.g. neisseria gonorrhoeae, chlamydia trachomatis. Non-STIs, e.g. haemophilus influenza, e.coli - Risk factors = same for STIs, e.g. not using barrier contraception, multiple sexual partners, younger age, previous STIs

Answer 169

- Women may present with symptoms of: - Pelvic or lower abdominal pain - Abnormal vaginal discharge - Abnormal bleeding (intermenstrual or postcoital) - Pain during sex (dyspareunia) - Fever - Dysuria

Answer 170

- Patients with pelvic inflammatory disease should have testing for causative organisms and other sexually transmitted infections: - NAAT swabs for gonorrhoea and chlamydia (and Mycoplasma genitalium if available) - HIV test - Syphilis test

Answer 171

- Where appropriate patients should be referred to a genitourinary medicine (GUM) specialist service for management and contact tracing. Antibiotics are started empirically, before swab results are obtained, to avoid a delay and complications: - A single dose of intramuscular ceftriaxone 1g (to cover gonorrhoea) - Doxycycline 100mg twice daily for 14 days (to cover chlamydia and Mycoplasma genitalium) - Metronidazole 400mg twice daily for 14 days (to cover anaerobes such as Gardnerella vaginalis) - Ceftriaxone and doxycycline will cover many other bacteria, including H. influenzae and E. coli

Answer 172

- Sepsis - Abscess - Infertility - Chronic pelvic pain - Ectopic pregnancy - Fitz-Hugh-Curtis syndrome

Answer 173

C. A should be small enough to pass spontaneously, B is likely too big to pass spontaneously but not urgent - elective, but C has signs of infection + AKI

Answer 174

A. CT urogram

Answer 175

- Trimethoprim - Cefalexin

Answer 176

C. Relaxes the smooth muscle in the bladder neck and prostate

Answer 177

B. Transrectal USS and biopsy

Answer 178

A. Calcium oxolate

Answer 179

A. Ascending transurethral

Answer 180

B. Membranous glomerulonephritis

Answer 181

A. Streptococcal tonsillitis

Answer 182

C. Bloody urine preceded by tonsillitis

Answer 183

D. Low protein, low potassium, low phosphate

Answer 184

Med school love this * Tall ‘tented’ T waves * P wave flattening * PR elongation * Wide QRS complex

Answer 185

Med school love this. ## Footnote Insulin shifts potassium into cells by stimulating the activity of Na⁺-H⁺ antiporter on cell membrane, promoting the entry of sodium into cells, which leads to activation of the Na⁺-K⁺ ATPase, causing an electrogenic influx of potassium. IV insulin leads to a dose-dependent decline in serum potassium levels. Dextrose is given to prevent hypoglycaemia.

Answer 186

- Breast cancer is the most common form of cancer in the UK. It mostly affects women and is rare in men (about 1% of UK cases). Around 1 in 8 women will develop breast cancer in their lifetime. - Risk factors: - Female (99% of breast cancers) - Increased oestrogen exposure (earlier onset of periods and later menopause) - More dense breast tissue (more glandular tissue) - Obesity - Smoking - Family history (first-degree relatives) - Oral contraceptive pill (but risk returns to normal after 10 years) - Combined HRT

Answer 187

- BRCA refers to the BReast CAncer gene. The BRCA genes are tumour suppressor genes. Mutations in these genes lead to an increased risk of breast cancer (as well as ovarian and other cancers): - BRCA1 gene is on chromosome 17 - BRCA2 gene is on chromosome 13 - There are other rarer genetic abnormalities associated with breast cancer (e.g., TP53 and PTEN genes).

Answer 188

- Ductal carcinoma in situ - Lobular carcinoma in situ - Invasive ductal carcinoma - Invasive lobular carcinoma (NST - no specific type) - Inflammatory breast cancer - Paget's disease of the nipple

Answer 189

- Lumps that are hard, irregular, painless or fixed in place - Lumps may be tethered to the skin or the chest wall - Nipple retraction - Skin dimpling or oedema (peau d’orange) - Lymphadenopathy, particularly in the axilla

Answer 190

- The NHS breast cancer screening program offers a MAMMOGRAM every 3 years to women aged 50 – 70 years - There are different recommendations for screening patients with a higher risk, i.e. those with first-degree relatives

Answer 191

- The NICE guidelines (updated January 2021) recommend a two week wait referral for suspected breast cancer for: - An unexplained breast lump in patients aged 30 or above - Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes) - An unexplained lump in the axilla in patients aged 30 or above - Skin changes suggestive of breast cancer - Once a patient has been referred for specialist services under a two week wait referral for suspected cancer, they should initially receive a triple diagnostic assessment comprising of: - CLINICAL ASSESSMENT (history and examination) - IMAGING (ultrasound or mammography) - US better in younger women, mammogram better in older women - BIOPSY (fine needle aspiration or core biopsy)

Answer 192

- You can remember the notable locations that breast cancer metastasis occur using 2 Ls and 2 Bs: - L - Lungs - L - Liver - B - Bones - B - Brain

Answer 193

- Surgery: - BREAST-CONSERVING SURGERY (e.g., wide local excision), usually coupled with radiotherapy. Can be offered reconstruction - MASECTOMY (removal of the whole breast), potentially with immediate or delayed breast reconstruction - breast implants or flap reconstruction - Axillary clearance if cancer cells found in the nodes - Radiotherapy - Chemotherapy - Hormone treatment - for patients with OESTROGEN-RECEPTOR POSITIVE breast cancer: - TAMOXIFEN for PREMENOPAUSAL WOMEN - AROMATASE INHIBITORS for POSTMENOPAUSAL WOMEN

Answer 194

A. Renal papilla, minor calyx, major calyx, renal pelvis, ureter, bladder, urethra

Answer 195

C. Thick ascending loop of Henle

Answer 196

D. Amino acids are reabsorbed with a K+ co-transporter

Answer 197

E. Somatic pudendal nerve (S2-S4)

Answer 198

D. Aldosterone causes decreased reabsorption of Na+

Answer 199

D. The medulla has two centres involved in the control of micturition; the storage and micturition centre

Answer 200

B. ADH promotes the release of aquaporins to decrease water retention

Answer 201

B. Hypovolaemia

Answer 202

B. Increased resorption of K+

Answer 203

D. Proximal part of the distal convoluted tubule

Answer 204

C. Bed rest

Answer 205

D. Urolithiasis

Answer 206

C. Ampulla

Answer 207

D. Suspensory ligament

Answer 208

E. Seminiferous tubules, rete testis, epididymis, vas deferens, urethra

Answer 209

D. Thickens cervical mucus

Answer 210

C. Tunica albuginea

Answer 211

E. Lutenizing hormone (LH)

Answer 212

B. Prolactin is normally inhibited by GABA

Answer 213

D. Menstrual, proliferative and secretory

Answer 214

C. Human chorionic gonadotrophin (hCG)

Answer 215

B. Vaginal candidiasis

Answer 216

E. Primordial germ cells

Answer 217

B. Varicocele

Answer 218

D. Phosphodiesterase type 5 (PDE-5) inhibitor

Answer 219

D. Increased FSH:LH ratio

Answer 220

A. Suspensory ligaments

Answer 221

B. Laparoscopy

Answer 222

A. Cortical reaction

Answer 223

C) Hypotension. (Postural) hypotension – SEs include (postural hypotension), dizziness, dry mouth

Answer 224

A. Chronic kidney disease

Answer 225

A. A hard and irregular mass

Answer 226

C. Refer to urology for surgery immediately

Answer 227

C. Cephalexin

Answer 228

A. Chemotherapy

Answer 229

A. Phosphodisesterase inhibitor (sildenafil)

Answer 230

C. IgA nephropathy

Answer 231

A. Prostatitis and Escherichia coli

Answer 232

A. Varicocele

Answer 233

A. Renal colic

Answer 234

A. Pyelonephritis

Answer 235

A. Intra renal acute kidney injury

Answer 236

B. Renal cell carcinoma

Answer 237

A. Transitional cell carcinoma

Answer 238

C. Ceftriaxone 500mg IMI with Azithromycin 1 gram orally STAT

Answer 239

A. Prednisolone

Answer 240

B. Prophylactic antibiotics for Pneumocystic pneumonia

Answer 241

1. Intrinsic 2. Pre-renal 3. Post-renal

Answer 242

a) Nephritic syndrome is characterised by inflammation of the kidney and is diagnosed by renal biopsy b) A child presenting with haematuria 4 weeks after a skin infection has post streptococcal nephritis c) IgA nephritis is the most common cause of nephritic syndrome in the UK

Answer 243

a) A patient with nephrotic syndrome presents with oedema and frothy urine b) ACE-I/ARB are used to reduce protein loss and slow progression of renal disease c) 25% of cases of nephrotic syndrome have no visible changes on biopsy

Answer 244

a) Bladder cancer classically presents with painless haematuria b) Kidney cancer presents with a triad of haematuria, flank pain, palpable abdominal mass c) FUNDS stands for frequency, urgency, nocturia, and discharge d) Cystitis should be treated with cefalexin and analgesia

Answer 245

a) Kidney stones are commonly found at the pelvic ureteric junction, the pelvic brim, and the vesicoureteral junction b) The diagnostic test for STI’s is Nucleic acid amplification testing c) 85% of patients with kidney stones present with haematuria

Answer 246

D. Ultrasound KUB

Answer 247

A. Tamsulosin

Answer 248

B. 5 alpha reductase inhibitor

Answer 249

E. Hydrocele

Answer 250

C. Prostatitis

Answer 251

A. Infertility

Answer 252

D. Cytoscopy with biopsy

Answer 253

B. Non-contrast helical CT scan

Answer 254

A. Rhabdomyolysis

Answer 255

a) Calcium gluconate

Answer 256

a. IgA nephropathy

Answer 257

A. Acute interstitial nephritis

Answer 258

A. Renal biopsy

Answer 259

6. Calcium, phosphate, alkaline phosphatase, PTH

Answer 260

A. Normal renal function

Answer 261

C. Oral iron replacement

Answer 262

C. Secondary hyperparathyroidism

Answer 263

D. Surgical removal

Answer 264

B. Chlamydia trachomatis

Answer 265

E. Pyelonephritis

Answer 266

B. Tamsulosin

Answer 267

D. Testicular torsion

Answer 268

A. Non-contrast CT of the kidneys, ureter, and bladder. This presentation is consistent with kidney stones. NCCT-KUB is the gold standard investigation for kidney stones. An ultrasound would be done instead of a CT if the patient was a pregnant person

Answer 269

B. Post-streptococcal glomerulonephritis

Answer 270

B. Ciprofloxacin

Answer 271

D. Start ACEi for high blood pressure

Answer 272

A. Neisseria gonorrhoea B. Gram-negative diplococci C. Ceftriaxone as an intramuscular injection D. Advise him to attend a genitourinary clinic or specialist sexual health service, use condoms whenever he has sex, get regular STI testing whilst sexually active, abstain from sex until treatment has been completed

Answer 273

A. Pre-renal, intra-renal, post-renal B. Pre-renal -\> hypotension (sepsis, etc), hypovolaemia (dehydration, acute blood loss, etc), low cardiac output (heart failure), low renal perfusion (NSAIDs, ACEIs) Renal -\> glomerulonephritis, vasculitis, acute tubular necrosis (can be ischaemic or nephrotoxic [gentamicin, radiocontrast media, cisplatin, etc]) Post-renal -\> stones (renal or bladder), BPH, prostate cancer, bladder cancer, blood clots, urethral stricture

Answer 274

A. Bladder cancer B. Flexible cytoscopy C. i) Transurethral resection of the bladder tumour (TURBT) is the surgical option for non-muscle invasive cancer. Radical cystectomy can be done in higher risk cancer and muscle-invasive cancers ii) For non-muscle invasive cancers, mitomycin C can be given around the time of TURBT. For higher risk, non-muscle invasive cancers, BCG can be given. For muscle-invasive cancers, MVAC (methotrexate, vinblastine, doxorubicin, cisplatin) chemotherapy can be given

Answer 275

A. IgA nephropathy (Berger's disease) B. 1. Heavy proteinuria (\>3.5g/24hrs) – shown on dipstick as ACR. 2. Hypoalbuminaemia (\<30g/L) – lost in urine. 3. Oedema – reduced oncotic pressure due to low albumin. 4. Hypercholesterolaemia – cholesterol is bound to albumin and synthesis goes wrong. Also, haematuria is usually mild or absent.

Answer 276

A. It is an anticholinergic drug. By inhibiting parasympathetic nervous system, it decreases detrusor excitability, preventing symptoms of urgency. B. Dry eyes and tachycardia. Others = dry mouth, dilated pupils/blurred vision, constipation, dizziness (postural hypotension), confusion

Answer 277

A. Positives: early detection of prostate ca, leads to better outcomes, simple, widely available blood test, cheap. Negatives: high rate of false positives, can cause anxiety, prostate ca often slow growing and never spread beyond the prostate, not requiring treatment B. Transrectal US guided prostate biopsy - Gleason grading