Passmed - Metabolic

Question 1

Features of a renal cell carcinoma

Answer 1

• Classic triad:
  
  • loin pain
  • haematuria
  • abdo mass
• pyrexia of unknown origin
• Paraneoplastic:
  
  • EPO secretion (polycythaemia)
  • PTH secretion (hypercalcaemia)
  • ACTH
• Varciocele

Question 2

Features of a varicocele:

Answer 2

• majoirty are left sided
• caused by a tumour compressing the vein or the SMA
• also known as stauffer syndrome
• thought to be due to increased levels of IL6

Question 3

Risk factors for RCC:

Answer 3

• middle aged man
• smoker
• von hippel lindau
• tuberous sclerosis
• Incidence of RCC is only slight increased in pts with ADPKD

Question 4

Features of testicular cancer:

Answer 4

• painless lump
• hydrocele
• gynaecomastia:
  
  • increased oestrogen:androgen ratio
  • germ cell tumours -> hCG -> Leydig cell dysfunction -> increases in both oestradiol and testosterone production, but rise in oestradiol is relatively greater than testosterone
  • leydig cell tumours -> directly secrete more oestradiol and ocnvert additiional androgen precursors to oestrogens

Question 5

Tumour markers of testicular cancer

Answer 5

• hCG: elevated in around 20% of seminomas
• AFP: elecated in around 80-85% of seminomas/non-seminomas
• LDH is elevated in around 40% of germ cell tumours

Question 6

Testicular cancer: Diagnosis, management and Prognosis

Answer 6

Dx: Ultrasound is first line

Mx:

- depends on seminoma vs non seminoma (yolk sac, teratoma, choriocarcinoma)
- Orchidectomy
- Chemo and Radio may be given depending on staging and tumour type 

Px:
- 95% survival for seminoma is stage 1, 85% if stage 1 Teratoma

Question 7

Overactive bladder signs, symptoms and management

Answer 7

• Storage symptoms only: urgency and frequency

Dx:

• bladder diaries should be done for 3 days
• Vaginal exam to exclude a prolapse and ability to initiate voluntary contraction of pelvic floor muscles
• urine dipstick and culture
• urodynamic studies
• Mx:
  
  • bladder training
  • Oxybutynin (Anti muscarinic)
  • Mirabegron if first line medication fails (beta 3 agonist)

Question 8

Toxic multinodular goitre features and RF:

Answer 8

Features:

• depression
• nervousness
• oligomenorrhoea
• hyperdefecation
• stare or lid lag
• warm, moist skin
• tachycardic
• tremor

RF:

• iodine deficiency
• age >40 yrs

Question 9

Investigations for MNG and associated results:

Answer 9

TSH: suppressed

T4: elevated

T3: elevated

I123 thyroid scan: multiple hot and cold areas

TSH receptor antibodies: negative

Thyroid perxoidase antibodies: negative

Question 10

MNG treatment algorithm

Answer 10

Non pregnant and no cancer worry:

- radioactive idoine 1st 
- Thyroid surgery 2nd

Suspicous of cancer:
- Thyroid surgery 1st

Pregnant:

- Antithyroid drugs 1st 
- Thyroid surgery 2nd line

Question 11

Key features of primary hyperaldosteronism and its RF

Answer 11

• Hypertension
• Nocturia, polyuria,
• Lethargy
• mood disturbance
• poor concentration

If hypokalaemic:

• muscle cramps/weakness
• paraesthesia
• Palpitations

RF:
- family history

Question 12

Investigations fo primary hyperaldosteronism

Answer 12

• plasma potassium: normal or low
• Aldosterone/renin RATIO: most reliable screening test
  
  • pt must be off any diuretics for 6 week and >20 indicates further investigation
• Fludrocortisone suppression test: most reliable rule in test
  
  • fludrocortisone is given over 4 days, +ve if aldosterone is not <6 over 4 days
• After rule in proceed to genetic testing and Adrenal villous sampling

Question 13

Treatment algorithm for primary hyperaldosteronism

Answer 13

Unilateral:

- 1st surgery
- 2nd aldosterone antagonist

Bilateral:

- 1st aldosterone antagonist 
- 2nd surgery (switch if there is an adrenal lesion greater than 2.5cm)

FHI:

- adults
	- 1st - glucocorticoids
	- 2nd - aldosterone antagonist 
- children 
	- 1st - amiloride
	- 2nd - eplenerone