Tuesday 28th Flashcards
1
Q
Who should have a PSA test? [7]
A
Abnormal feeling prostate on DRE
Symptoms of locally advanced or metastatic disease
>50 years on request if appropriately counselled
>45 if FH or black ethnicity on request if appropriately counselled
Men with LUTS – can be prognostic for progression of LUTS (CONSIDER)
Haematuria (CONSIDER)
Erectile dysfunction (CONSIDER)
2
Q
Does a normal PSA mean there is no cancer? [1]
A
<0.5ng/ml – 6.6%
- 6-1.0ng/ml – 10.1%
- 1-2.0ng/ml – 17%
- 1-3.0ng/ml – 23.9%
- 1-4.0ng/ml – 26.9%
Often, will use figures of over 3 to Dx
3
Q
Best way to Ix prostate cancer? [1]
A
MRI best way, most accurate and avoids unnecessary biopsy
4
Q
Name 3 possible prostate Ca Tx [3]
A
EBRT/ADT
Brachytherapy
Focal therapies
Active surveillance
WW
5
Q
What is EBRT in terms of urology and when is it used? [2]
A
External beam radiation therapy (EBRT) In EBRT, beams of radiation are focused on the prostate gland from a machine outside the body. This type of radiation can be used to try to cure earlier stage cancers, or to help relieve symptoms such as bone pain if the cancer has spread to a specific area of bone
6
Q
What is ADT in terms of urology and how does it work? [2]
A
Hormone therapy for prostate cancer is also known as androgen deprivation therapy (ADT). Prostate cancer cannot grow or survive without androgens, which include testosterone and other male hormones. Hormone therapy decreases the amount of androgens in a man’s body
7
Q
For locally advanced and metastatic disease, what is used in prostate cancer? [2]
A
For locally advanced and metastatic disease we use androgen deprivation therapy
- includes Degarelix
8
Q
What is Degarelix now preferred for castration? [1]
A
- [used to be Leuprorelin, but Degarlix castrates at a faster rate]
9
Q
Which hormone does prostate cancer require? [1]
A
Testerone
10
Q
What should be urgently ordered when Sx of cord compression? [1]
A
MRI spine
11
Q
Medical Mx for cord compression [2]
A
- Steroids [e.g. dexamethasone]
- PPI
- [also bedrest, RT/neurosurgery]
12
Q
Two types of haematuria [1]
A
Visible, invisible
13
Q
What level of RBC would be concerning urine dipstick? [1]
A
Above 1 I think
14
Q
Difference between Ix visible from invisible haematuria [2]
A
Visible -> flexible cystoscopy + non-contrast CT
Invisible -> flexible cystoscopy + CTIVU
15
Q
Which LUT Sx is especially a concern for cancer? [1]
A
Nocturnal enuresis
16
Q
Three ways of monitoring incontinence [3]
A
IPSS score, frequency volume chart, post void residual
17
Q
What’s a normal flow rate, what’s a concerning flow rate? [2]
A
Normal is like 15 ml/s, concerning would be like 5 ml/s
18
Q
What’s one of the most common causes of a transiently raised PSA? [2]
A
- Infection [like prostitis]
- Trauma
19
Q
Which Ix for calculi should be done? [4]
A
- NCCT
- U+Es
- Ca
- uric acid
20
Q
What should be excluded in calculi? [1]
A
Sepsis
21
Q
Give some examples of urological emergencies [2]
A
Testicular torsion
Uro-sepsis including epididymo-orchitis, pyelonephritis, Fournier’s gangrene
Ureteric colic
Acute retention
High pressure chronic retention/interactive obstructive uropathy
Hyperkalaemia and renal failure
Haematuria
Trauma to the urinary tract
Paraphimosis
22
Q
painless swelling superotemporal aspect of orbit -> squamous epithelium and hair follicles [1]
A
Dermoid cysts are embryological remnants and may be lined by hair and squamous epithelium (like teratomas)
23
Q
Where are dermoid cysts often located? [1]
A
They are often located in the midline and may be linked to deeper structures resulting in a dumbbell shape to the lesion
24
Q
Mx of dermoid cyst [1]
A
Complete excision is requires as they have a propensity to local recurrence if not excised.
25
Where do desmoid tumour develop from? [1]
Desmoid tumours are a different entity, they most commonly develop in ligaments and tendons
26
How should dermoid tumours be Mx? [2]
They are also referred to as aggressive fibromatosis and consist of fibroblast dense lesions (resembling scar tissue). They should be managed in a similar manner to soft tissue sarcomas.
27
What are the three main skin malignancies? [1]
Skin malignancies include basal cell carcinoma, squamous cell carcinoma and malignant melanoma.
28
Features of basal cell carcinoma [3]
Most common form of skin cancer.
Commonly occur on sun exposed sites apart from the ear.
Sub types include nodular, morphoeic, superficial and pigmented.
Typically slow growing with low metastatic potential.
Standard surgical excision, topical chemotherapy and radiotherapy are all successful.
As a minimum a diagnostic punch biopsy should be taken if treatment other than standard surgical excision is planned.
29
Features of squamous cell carcinomas [3]
Again related to sun exposure.
May arise in pre - existing solar keratoses.
May metastasize if left.
Immunosupression (e.g. following transplant), increases risk.
Wide local excision is the treatment of choice and where a diagnostic excision biopsy has demonstrated SCC, repeat surgery to gain adequate margins may be required.
30
Main diagnostic features for malignant melanoma [3]
The main diagnostic features (major criteria):
Change in size
Change in shape
Change in colour
31
Secondary features of malignant melanoma [4]
Diameter \>6mm
Inflammation
Oozing or bleeding
Altered sensation
32
Tx for malignant melanomas [2]
Suspicious lesions should undergo excision biopsy. The lesion should be removed in completely as incision biopsy can make subsequent histopathological assessment difficult.
Once the diagnosis is confirmed the pathology report should be reviewed to determine whether further re-excision of margins is required
33
How large should the margin be for a a 2-4mm thick lesion? [1]
2-3cm [depending upon site and pathological features]
34
Features of Kaposi Sarcoma [3]
Tumour of vascular and lymphatic endothelium.
Purple cutaneous nodules.
Associated with immuno supression.
Classical form affects elderly males and is slow growing.
Immunosupression form is much more aggressive and tends to affect those with HIV related disease.
35
Give examples of non-malignant skin diseases [2]
Dermatitis herpetiformis, dermatofibroma, pyogenic granuloma, acanthuses nigraicans
36
Features of dermatitis herpetiformis [2]
Chronic itchy clusters of blisters.
Linked to underlying gluten enteropathy (coeliac disease).
37
Features of dermatofibroma [4]
Benign lesion.
Firm elevated nodules.
Usually history of trauma.
Lesion consists of histiocytes, blood vessels and fibrotic changes.
38
features of pyogenic granuloma [4]
Overgrowth of blood vessels.
Red nodules.
Usually follow trauma.
May mimic amelanotic melanoma.
39
Features of acanthuses nigricans [4]
Brown to black, poorly defined, velvety hyperpigmentation of the skin.
Usually found in body folds such as the posterior and lateral folds of the neck, the axilla, groin, umbilicus, forehead, and other areas.
The most common cause of acanthosis nigricans is insulin resistance, which leads to increased circulating insulin levels. Insulin spillover into the skin results in its abnormal increase in growth (hyperplasia of the skin).
In the context of a malignant disease, acanthosis nigricans is a paraneoplastic syndrome and is then commonly referred to as acanthosis nigricans maligna. Involvement of mucous membranes is rare and suggests a coexisting malignant condition.
40
A 56-year-old lady presents with a 6 month history of dysphagia to solids. She has a long history of retrosternal chest pain that is worse on lying flat and bending forwards. She undergoes an upper GI endoscopy where a smooth stricture is identified [1]
Peptic stricture 73%
A six month history of dysphagia is a relatively long history and makes malignancy less likely. The lesion should be biopsied for histological confirmation. Long standing oesophagitis may be complicated by the development of strictures, Barretts oesophagus or both.
41
A 76-year-old man presents with a 5 week history of progressive dysphagia. An upper GI endoscopy is performed and the surgeon notices changes that are compatible with Barretts oesophagus. The oesophagus is filled with food debris that cannot be cleared and the endoscope encounters a resistance that cannot be passed. [1]
Adenocarcinoma of the oesophagus 68%
A short history of dysphagia together with food debris and Barretts changes makes adenocarcinoma the most likely diagnosis.
42
A 22-year-old man presents with a 5 month history of episodic retrosternal chest pain together with episodes of dysphagia to liquids. An upper GI endoscopy is performed and no mucosal abnormality is seen. [1]
Motility disorder 84%
Dysphagia that is episodic and varies between solids and liquids is more likely to represent a motility disorder.
43
Mallory-Weiss tear signs [2]
Usually history of antecedent vomiting. This is then followed by the vomiting of a small amount of blood. There is usually little in the way of systemic disturbance or prior symptoms.
44
Hiatus hernia signs [2]
Often longstanding history of dyspepsia, patients are often overweight. Uncomplicated hiatus hernias should not be associated with dysphagia or haematemesis.
45
Oesophageal rupture signs [2]
Complete disruption of the oesophageal wall in absence of per-existing pathology. Left postero-lateral oesophageal is commonest site (2-3cm from OG junction). Suspect in patients with severe chest pain without cardiac diagnosis and signs suggestive of pneumonia without convincing history, where there is history of vomiting. Erect CXR shows infiltrate or effusion in 90% of cases(1).
46
Squamous cell carcinoma signs [2]
History of progressive dysphagia. Often signs of weight loss. Usually little or no history of previous GORD type symptoms.
47
How to diagnose oesophageal diseases [2]
Most of the differential diagnoses listed above can be accurately categorised by upper GI endoscopy (usually most patients). Where this fails to demonstrate a mechanical stricture the use of pH and manometry studies together with radiological contrast swallows will facilitate the diagnosis
48
Which bacterium commonly causes food poisoning reheated rice? [1]
Bacillus cereus
49
How would Campylobacter and Shigella present in food poisoning? [1]
Campylobacter and Shigella cause bacterial food poisoning and would likely have a longer history with bloody diarrhoea.
50
Define traveller' diarrhoea [2]
Travellers' diarrhoea may be defined as at least 3 loose to watery stools in 24 hours with or without one of more of abdominal cramps, fever, nausea, vomiting or blood in the stool
51
Commonest cause of traveller's diarrhoea [1]
E.coli
52
How would cholera typically present? [2]
Profuse, watery diarrhoea
Severe dehydration resulting in weight loss
Not common amongst travellers
53
Incubation period of Giardasis [1]
Incubation period
1-6 hrs: Staphylococcus aureus, Bacillus cereus\*
12-48 hrs: Salmonella, Escherichia coli
48-72 hrs: Shigella, Campylobacter
\> 7 days: Giardiasis, Amoebiasis
54
Define E.coli [4]
Escherichia coli is a facultative anaerobic, lactose-fermenting, Gram negative rod which is a normal gut commensal.
55
What can E.coli infections cause? [3]
diarrhoeal illnesses
UTIs
neonatal meningitis
56
Which type of E.coli is commonly spread by ground beef? [1]
E. coli O157:H7 is a particular strain associated with severe, haemorrhagic, watery diarrhoea. It has a high mortality rate and can be complicated by haemolytic uraemic syndrome. It is often spread by contaminated ground beef.
57
Mx of patient on heparin for PE that contracts HIP [1]
Switch to direct throbbing inhibitor [argatroban]
58
How does heparin-induced thrombocytopenia occur? [1]
Heparin-induced thrombocytopenia occurs due to the production of auto-antibodies against heparin and platelet factor IV.
59
How long does it take for HIT to present? [1]
It tends to start at 5-10 days into treatment, with the typical presentation being blood clots forming in the context of recently started heparin and low platelets
60
What are the two main types of heparin? [2]
There are two main types of heparin - unfractionated, 'standard' heparin or low molecular weight heparin (LMWH).
61
How does heparin act? [1]
Activate antithrombin III
62
Compare action of unfractioned heparin to LWMH [2]
Unfractionated heparin forms a complex which inhibits thrombin, factors Xa, IXa, XIa and XIIa. LMWH however only increases the action of antithrombin III on factor Xa
63
Adverse effects of heparins [4]
bleeding
thrombocytopenia - see below
osteoporosis and an increased risk of fractures
hyperkalaemia - this is thought to be caused by inhibition of aldosterone secretion
64
Compare administration and duration of action of standard to LWMH [2]
standard: IV, short action
LWMH: subcut, long action
65
Features of HIT [3]
Heparin-induced thrombocytopaenia (HIT)
immune mediated - antibodies form against complexes of platelet factor 4 (PF4) and heparin
these antibodies bind to the PF4-heparin complexes on the platelet surface and induce platelet activation by cross-linking FcγIIA receptors
usually does not develop until after 5-10 days of treatment
despite being associated with low platelets HIT is actually a prothrombotic condition
features include a greater than 50% reduction in platelets, thrombosis and skin allergy
address need for ongoing anticoagulation:
direct thrombin inhibitor e.g. argatroban
danaparoid
66
How can heparin overdose be managed? What about for LMWH? [2]
Heparin overdose may be reversed by protamine sulphate, although this only partially reverses the effect of LMWH.
67
Are liver enzymes good at looking at liver function? If not, then what is? [2]
Liver enzymes are a poor way to look at liver function - they are usually low in end-stage cirrhosis whereas coagulation and albumin are better measures
68
Common causes of acute liver failure [4]
paracetamol overdose
alcohol
viral hepatitis (usually A or B)
acute fatty liver of pregnancy
69
Features of acute liver failure [5]
Features\*
jaundice
coagulopathy: raised prothrombin time
hypoalbuminaemia
hepatic encephalopathy
renal failure is common ('hepatorenal syndrome')
\*remember that 'liver function tests' do not always accurately reflect the synthetic function of the liver. This is best assessed by looking at the prothrombin time and albumin level.
70
What is PCV? [4]
Polycythaemia vera is a myeloproliferative disorder caused by clonal proliferation of a marrow stem cell leading to an increase in red cell volume, often accompanied by overproduction of neutrophils and platelets
71
Features of PCV [3]
It has a peak incidence in the sixth decade, with typical features including hyperviscosity, pruritus and splenomegaly.
72
Mx of PCV [3]
Management
aspirin
reduces the risk of thrombotic events
venesection
first-line treatment to keep the haemoglobin in the normal range
chemotherapy
hydroxyurea - slight increased risk of secondary leukaemia
phosphorus-32 therapy
73
Prognosis of PCV [3]
Prognosis
thrombotic events are a significant cause of morbidity and mortality
5-15% of patients progress to myelofibrosis
5-15% of patients progress to acute leukaemia (risk increased with chemotherapy treatment)
74
Suggest types of sickle cell crisis [5]
thrombotic, 'painful crises'
sequestration
acute chest syndrome
aplastic
haemolytic
75
Thrombotic sickle cell crisis [4]
also known as painful crises or vaso-occlusive crises
precipitated by infection, dehydration, deoxygenation
painful vaso-occlusive crises should be diagnosed clinically - there isn't one test that can confirm them although tests may be done to exclude other complications
infarcts occur in various organs including the bones (e.g. avascular necrosis of hip, hand-foot syndrome in children, lungs, spleen and brain
76
Sequestration sickle cell crisis [2]
sickling within organs such as the spleen or lungs causes pooling of blood with worsening of the anaemia
associated with an increased reticulocyte count
77
Acute chest syndrome sickle cell crisis [2]
dyspnoea, chest pain, pulmonary infiltrates, low pO2
the most common cause of death after childhood
78
Aplastic crisis sickle cell [3]
caused by infection with parvovirus
sudden fall in haemoglobin
bone marrow suppression causes a reduced reticulocyte count
79
Haemolytic sickle cell crisis [2]
rare
fall in haemoglobin due an increased rate of haemolysis
80
Name a drug that is CI with sildenafil and why? [2]
PDE 5 inhibitors (e.g. sildenafil) - contraindicated by nitrates and nicorandil
Nitrates can cause profound hypotension when used in combination with sildenafil so alternative options should be discussed with this patient.
81
SE of sildenafil [5]
visual disturbances e.g. blue discolouration, non-arteritic anterior ischaemic neuropathy
nasal congestion
flushing
gastrointestinal side-effects
headache
The blue pill, Viagra, causes blue discolouration of vision.
82
Which initial surgical option is available for cancers obstructing the colon?
A loop colostomy is used to defunction and decompress the distal colon in obstructing cancers
83
What does a loop colostomy create?
A stoma with 2 openings:
- one connected to the functioning part of your bowel
- and the other leads into the distal portion of the bowel.
- This will defunction and decompress the distal colon, and the stoma can be reversed at a later date. Due to the nature and location of the lesion here, this is the procedure of choice.
84
How does spouting compare for the small bowel and colonic stomas? [2]
With bowel stomas, the type method of construction and to a lesser extent the site will be determined by the contents of the bowel. In practice, small bowel stomas should be spouted so that their irritant contents are not in contact with the skin. Colonic stomas do not need to be spouted as their contents are less irritant.
85
Why is the site of stoma marked important with the patient prior to surgery? [2]
In the ideal situation, the site of the stoma should be marked with the patient prior to surgery. Stoma siting is important as it will ultimately influence the ability of the patient to manage their stoma and also reduce the risk of leakage. Leakage of stoma contents and subsequent maceration of the surrounding skin can rapidly progress into a spiralling loss of control of stoma contents.
86
Compare ileostomy to a colstomy bag [6]
Ileostomy:
- right iliac fossa
- spouted
- liquid output
Colostomy:
- location varies
- flushed appearance
- solid output
87
What can long-term mechanical ventilation in trauma patients results in? [1]
Long term mechanical ventilation in trauma patients can result in tracheo-oesophageal fistula [TOF] formation
88
What can TOF result in? [2]
Long term mechanical ventilation can result in tracheo-oesophageal fistula (TOF) formation, which increases the risk of ventilator-associated pneumonias and aspiration pneumonias - the latter caused by aspirated stomach contents.
89
Why are blood levels for lithium taken frequently? [1]
Blood levels are taken frequently for lithium as it has a very narrow therapeutic index (0.6-1.2).
90
When does lithium toxicity occur? [1]
levels above 1.5mmol/l
91
What may toxicity lithium be precipitated by? [3]
dehydration
renal failure
drugs: diuretics (especially thiazides), ACE inhibitors/angiotensin II receptor blockers, NSAIDs and metronidazole.
92
features of toxicity with lithium [3]
coarse tremor (a fine tremor is seen in therapeutic levels)
hyperreflexia
acute confusion
polyuria
seizure
coma
93
Mx of lithium toxicity [3]
mild-moderate toxicity may respond to volume resuscitation with normal saline
haemodialysis may be needed in severe toxicity
sodium bicarbonate is sometimes used but there is limited evidence to support this. By increasing the alkalinity of the urine it promotes lithium excretion
94
10 y/o girl with SoB and fatigue on CXR
The x-ray shows cardiomegaly and features of pulmonary oedema including fluid in the horizontal fissure.
Normally a PA film is more accurate in determining heart size but given the extent of the cardiomegaly it is reasonable to state that the heart is enlarged, even withstanding the fact it is an AP film.
95
What do the arrows represent? [3]
96
What does the ECG show?
ECG showing pericarditis. Note the widespread nature of the ST elevation and the PR depression
97
Compare cANCA to pANCA
98
Go through the GRACE risk assessment for malignant carcinomas
99
Typical presentations of gastroenteritis including E.coli, giardasis, cholera, shigella, staph aureus, campylobactera, bacillus cereus, amoebiasis
100
What does this ECG show?
HOCM including LVH and T wave inversion
