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CCE AR version > Urology > Flashcards

Urology Flashcards

1
Q

What are the indications for dialysis?

A

AEIOU
Acidosis
Electrolyte abnormalities with ECG changes
Intoxication with SLIME - salicylates, lithium, isopropanol, methanol, ethylene glycol
Overloaded with fluid
Uremic symptoms - pericarditis or encephalopathy

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2
Q

A 62 year old man has a 5 month hx of fatigue, perineal discomfort, lower back pain and loin pain. He experiences pain on micturition. What is the likely diagnosis?

A

Chronic bacterial prostatitis

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3
Q

60 year old man presents with dysuria and urgency. He gets some suprapubic pain which is relieved when lying supine and occasional terminal haematuria. there is no abnormality on examining the abdomen. What is the likely diagnosis?

A

Bladder calculi

Painful haematuria suggests this rather than malignancy

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4
Q

72 year old man presents to ED with acute back pain and leg weakness. He has been experiencing hesitancy and dribbling of urine for 12 months. On examination he has spastic paraparesis and palpable bladder. What is the likely diagnosis?

A

Prostate cancer
Signs of collapsed vertebrae - mets
Spinal cord compression - dorsal, stamping gait due to proprioceptive loss

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5
Q

What is the triad of symptoms associated with renal cell carcinoma?

A

Haematuria
Loin pain
Abdo pain

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6
Q

What is nephrotic syndrome?

A

Too much protein excreted by kidney

Patient usually presents with oedema around the eyes and legs

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7
Q

What is the first line treatment for benign prostatic hyperplasia?

A

Tamulosin - alpha blocker

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8
Q

What is the second line treatment for benign prostatic hyperplasia?

A

Finasteride

Alpha reductase inhibitor which reduces dihydrotestosterone and therefore prostate volume

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9
Q

What should patients taking finasteride be warned about contraception?

A

Use barrier contraception as it is excreted in semen and can cause birth defects in the foetus

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10
Q

What factors in the history would make you worry about bladder malignancy?

A

Painless haematuria
smoking
Palpable mass
Occupational exposure to aniline dyes and rubber

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11
Q

What is the first line painkiller for renal colic pain?

A

Disclofenac rectally

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12
Q

A 55 year old man presents to his GP with a painless lump in his right testicle which he has noticed over the last few weeks. A blood test shows normal alpha feto protein. He is found to have testicular cancer. What type is he most likely to have?

A

Seminoma - age and normal AFP

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13
Q

What is paraphimosis?

A

Complication of urinary catheterisation if the health professional forgets to replace the foreskin

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14
Q

What is the management for paraphimosis?

A

Attempted reduction by applying cold compresses to area and applying sustained firm pressure
If this fails, surgical management may be required

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15
Q

What is balanitis?

A

Infection of glans usually caused by streptococcus or staph

Common in diabetics

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16
Q

On which side are varicocoeles most likely to occur?

A

Left side due to:
Angle at which left testicular vein joins left renal vein
Lack of valves

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17
Q

Which veins are affected in a varicocoele?

A

Pampiniform plexus

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18
Q

What is the first line treatment for stress incontinence?

A

Pelvic floor exercises

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19
Q

What treatments are used in urge incontinence?

A

Bladder retraining

Oxybutynin - anticholinergic

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20
Q

A 21 year old man presents with malaise fever and bilateral large tender testes. What is the likely diagnosis?

A

Orchitis

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21
Q

A 27 year old man complains that there is a lump on his right testicle which transilluminates relatively poorly. He had a vasectomy two years earlier. Examination reveals a small non tender smooth 1cm mass arising from superior pole of testis. What is the likely diagnosis?

A

Spermatocoele

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22
Q

What are symptoms of hypercalcaemia?

A 
Bones: arthralgia, pseudogout
Moans: depression 
Stones: renal colic
Groans: peptic ulceration 
Constipation, polyuria and nocturia
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23
Q

What can be a devastating consequence of correcting hyponatraemia too quickly?

A

Osmotic demyelination syndrome

Central pontine demyelination

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24
Q

What are the 5 Rs of IV fluid therapy?

A 
Resuscitation
Routine maintenance
Replacement
Redistribution
Reassessment
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25
Q

Describe how total body water is divided up

A

Extracellular: 20% Na Cl HCO3
Intracellular: 40% K

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26
Q

What components of the extracellular compartment are there?

A

Intravascular: haematocrit and plasma

Interstitial

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27
Q

What contributes to plasma oncotic pressure?

A

Albumin
Haemoglobin
Globulin

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28
Q

Where can fluids be lost from?

A

Kidney
GIT
Skin
Lungs

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29
Q

What is the average daily intake of water sodium and potassium?

A

Water 25-35ml/kg/day
Sodium 1mmol/kg/day
Potassium 1mmol/kg/day

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30
Q

What is insensible loss of fluid?

A

Evaporation of water from lungs and skin

0.5L - 1L/day

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31
Q

How much fluid is lost from the GI tract per day?

A

100-150ml

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32
Q

What factors can negatively affect fluid balance?

A

Changes in albumin
Changes in potassium
Malnutrition

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33
Q

Why can liver disease lead to oedema?

A

Reduced albumin levels

Reduces plasma oncotic pressure and intravascular volume

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34
Q

What is crystalloid fluid?

A

Glucose or salt containing fluids
0.9% saline
Hartmanns solution
5% dextrose

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35
Q

What are colloid fluids?

A 
Microscopic particles: starch or protein suspended in crystalloid
Used for Intravascular volume expansion
6% hydroxyethyl starch 
4% succinylated gelatin
20% albumin
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36
Q

What is a balanced salt solution?

A

Crystalloid containing electrolytes in a concentration as close to plasma as possible
Ringers lactate
Hartmanns solution

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37
Q

Which fluids are better for interstitial volume correction?

A

Crystalloids

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38
Q

What imaging would you do to confirm a suspected prostatic malignancy?

A

Trans rectal ultrasonography

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39
Q

What is a Gleason score?

A

Evaluate prognosis of men with prostate cancer using samples from prostate biopsy
Cancers with higher Gleason score are more aggressive and have a worse prognosis, score 1-10

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40
Q

What is goserelin?

A

LH hormone releasing agonist

Suppress production of sex hormones

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41
Q

What characterises autosomal dominant Polycystic kidney disease?

A

Multiple bilateral renal cysts
Cyst formation in other organs such as pancreas and liver
Intracranial aneurysms

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42
Q

A 67 year old man is admitted with a ruptured infrarenal abdominal aortic aneurysm and undergoes a successful repair. Post operatively, urine output is poor despite adequate central venous pressure after control of the aneurysm. What is the likely problem?

A

Acute tubular necrosis

Common after major/emergency surgery when there are periods of prolonged hypotension

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43
Q

Which drugs could precipitate urinary retention?

A

Anticholinergic - TCAs
Antipsychotics - chlopromazine
Opiate analgesics

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44
Q

What are the 3 most common causes of end stage kidney disease?

A

Diabetes
Hypertension
Glomerulopathies

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45
Q

What are the different classifications of glomerulopathies? What are characteristics of each?

A

Nephrotic syndrome: massive proteinuria, hypoalbuminaemia, oedema, lipiduria, hyperlipidaemia
Acute glomerulonephritits (nephritic): haematuria, proteinuria, oedema, HTN, transient renal impairment
Rapidly progressive glomerulonephritits: acute nephritis, focal necrosis, rapidly progressing renal failure
Asymptomatic haematuria/proteinuria

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46
Q

What is the difference between bland and active urine sediments?

A

Active: cellular elements, red or white cells, or casts. Implies a process actively damaging your kidneys, causing them to bleed or get inflamed
Bland: other elements, crystals, protein, and urinary casts. May imply a more serious, long-standing kidney problem such as uncontrolled diabetes

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47
Q

What are negative prognostic factors for glomerulopathies?

A

HTN

Greater degree renal impairment

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48
Q

What are pathological changes seen in diabetic nephropathy?

A

Glomerular basement membrane thickening
Mesangial expansion
Glomerulosclerosis

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49
Q

What is the commonest form of glomerulonephritits worldwide?

A

IgA nephropathy

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50
Q

What is the definition of chronic kidney disease?

A

GFR 65 mg/mmol

Protein/creatinine ratio 100mg/mmol

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51
Q

List some causes of chronic kidney disease

A

Congenital: polycystic kidney disease
Glomerular disease: focal glomerulosclerosis, SLE, wegeners granulomatosis, HUS, TTP
Vascular disease: hypertensive nephrosclerosis, vasculitis
Tubulointerstitial disease: tubulointerstitial nephritis, reflux nephropathy, multiple myeloma
Urinary tract obstruction: calculus disease, prostatic disease, pelvic tumour

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52
Q

What are uraemic symptoms of CKD?

A 
Malaise
Loss of appetite
Insomnia
Nocturia and polyuria 
Itching
Nausea, vomiting, diarrhoea
Paraesthesia due to polyneuropathy
Restless legs syndrome 
Bone pain - metabolic bone disease 
Tetany - hypocalcaemia 
Peripheral and pulmonary oedema 
Anaemia symptoms 
Amenorrhoea/erectile dysfunction
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53
Q

What are red cell and granular casts?

A

Granular: abnormal cells in tubular lumen, indicate active renal disease
Red cell: glomerulonephritits

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54
Q

What are some complications of chronic kidney disease?

A 
Anaemia 
Bone disease - renal osteodystrophy 
Skin disease - itching 
Nephrogenic systemic fibrosis 
GI: decreased gastric emptying and increased redux 
Gout
Lipid metabolism abnormalities 
Hyperprolactinaemia 
Decreased testosterone - erectile dysfunction 
Oligomenorrhoea or amenorrhoea 
Impaired growth in children 
Abnormal thyroid hormone levels 
Dialysis dementia 
Psychiatric problems 
Median nerve compression
Restless leg syndrome 
Polyneuropathy 
Calciphylaxis 
Cardiovascular disease 
Malignancy
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55
Q

What is renoprotective management for chronic kidney disease?

A 
Ace inhibitor 
Angiotensin receptor blocker 
Diuretic 
Calcium channel blocker 
Statins 
Stop smoking
Treat diabetes
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56
Q

What are treatment aims for chronic kidney disease renoprotection?

A

BP

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57
Q

What can be complications of haemodialysis?

A 
Hypotension 
Anaphylaxis to ethylene oxide 
Hard water syndrome 
Haemolytic reaction
Air embolism
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58
Q

What can be complications of continuous ambulatory peritoneal dialysis?

A 
Peritonitis 
Infection around catheter site 
Constipation 
Pleural effusion 
Failure of peritoneal membrane function 
Sclerosing peritonitis
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59
Q

What are contraindications to continuous ambulatory peritoneal dialysis?

A 
Previous peritonitis causing adhesions
Presence of a stoma
Active intra abdominal sepsis 
Abdominal hernia 
Visual impairment - difficulty performing exchanges
Severe arthritis
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60
Q

What are complications of renal transplant?

A 
Acute tubular necrosis 
Technical failures - occlusion or stenosis of anastamosis, urinary leaks 
Acute rejection 
Infection - CMV 
Post transplant lymphoproliferative disorder 
Chronic allograft nephropathy 
Malignancy 
CV disease 
Post transplant osteoporosis 
Recurrent disease
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61
Q

What are risk factors for the development of an inguinal hernia?

A 
Make
Old age 
Smoking
Family history 
Prematurity 
Arterial aneurysm 
COPD
Obesity
Pregnancy 
Peritoneal dialysis 
Collagen vascular disease 
Previous open appendectomy
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62
Q

What are the boundaries of hesselbachs triangle?

A

Inferior: inguinal ligament
Lateral: inferior epigastric artery and vein
Medial: lateral border of rectus abdominus

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63
Q

In which type of inguinal hernia is strangulation most common?

A

Indirect - narrow neck

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64
Q

Describe what happens when a piece of bowel gets strangulated in an inguinal hernia

A

Segment of intestine prolapses through defect in anterior abdominal wall
Sequestration of fluid within lumen of herniated bowel
Impaired lymph and venous drainage which compounds swelling
Arterial supply becomes impaired
Gangrene ensues and if left untreated, perforation occurs

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65
Q

What are the different sub classifications of inguinal hernias?

A

Reducible
Irreducible or incarcerated
Strangulated

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66
Q

What are possible complications of an inguinal hernia repair?

A 
Urinary retention post operative 
Scrotal haematoma 
Wound seroma
Inguinal wound haematoma 
Wound infection 
Division of vas deferens
Mesh rejection 
Dysejaculation post surgery 
Bowel obstruction post surgery
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67
Q

In which babies are hydrocoeles more common?

A

Premature

Testes descend late

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68
Q

What are some possible complications of a hydrocoele?

A 
Inguinal hernia 
Testicular injury from surgery
Lower extremity oedema
Testicular atrophy 
Hydronephrosis 
Infertility
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69
Q

What factors make up nephrotic syndrome?

A

Proteinuria
Hypoalbuminaemia
Oedema

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70
Q

What can repeated use of sodium chloride cause? And what are some consequences of this?

A

Hyperchloraemia
Reduce renal blood flow so lead to Hyperchloraemic acidosis
GIT mucosal acidosis
Ileus

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71
Q

What are balanced Crystalloids? What benefits do they have over NaCl?

A

Hartmanns/ringer lactate
Lower amounts of sodium and chloride compared to other Crystalloids
Contain K, Ca, Mg, lactate, reduce acidosis

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72
Q

What are risks of using 5% dextrose and 0.18% sodium chloride/4% dextrose?

A

Hyponatraemia in elderly and children with SIADH

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73
Q

Name an isotonic crystalloid fluid which can be used when prescribing fluids

A

0.9% sodium chloride
Ringers lactate
Hartmanns solution

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74
Q

Name a hypotonic crystalloid fluid which can be used when prescribing fluids

A

0.18% sodium chloride/4% dextrose

5% dextrose (initially isotonic)

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75
Q

Describe a hypertonic crystalloid solution which can be used when prescribing fluids

A

3% sodium chloride

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76
Q

Which fluid is most useful to give in hypoglycaemia?

A

5% dextrose

25% or 50% glucose

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77
Q

Which fluid is most useful to give in a hypotensive patient?

A

Hartmanns
Ringers lactate
0.9% sodium chloride

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78
Q

Which fluid is most useful in a hyponatraemic patient?

A

0.9% sodium chloride

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79
Q

What are some indications for IV fluids?

A

Pre operative resuscitation: before emergency surgery, elective surgery in patient with sepsis
Replacement of abnormal losses: vomiting, diarrhoea, ileostomy bags
Provision of normal daily requirements if patient is nil by mouth
Post operative resuscitation
Electrolyte disorders

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80
Q

What is the constitution of Hartmanns solution?

A 
In 1L:
2mmol Ca
29mmol HCO3
110 mmol Cl
131 mmol Na
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81
Q

What are risks of giving IV fluids?

A

Hyponatraemia
Sodium/chloride and water overload
Pulmonary oedema

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82
Q

How can you monitor patients receiving IV fluid?

A 
Clinical examination: cap refil, pulse, BP, jvp, skin turgor, auscultate lungs and heart sounds, oedema, urine output
Fluid balance charts 
Regular weighing (daily)
Daily U and Es 
Serum magnesium
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83
Q

Give examples of when fluid resuscitation is useful

A

Blood loss from injury or surgery
Plasma loss from burns, pancreatitis
GI or renal losses of salt/water

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84
Q

What is the recommendation for IV fluid for resuscitation purposes?

A

500ml of balanced crystalloid stat (less than 15 mins)

250ml if cardiac failure

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85
Q

What are the principles of fluid replacement?

A

Daily maintenance requirements

Plus like for like water and electrolyte replacement for any losses

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86
Q

What are the aims of fluid maintenance?

A

Restore insensible loss 500-1000ml
Provide sufficient water and electrolytes to maintain normal status of body fluid compartments
Sufficient water to enable kidney to excrete waste products 500-1500ml

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87
Q

What signs on clinical examination would make you think that a patient needs some IV fluid?

A 
Systolic blood pressure less than 100
Heart rate more than 90
Cap refil more than 2 secs or peripheries cold to touch 
Resp rate more than 20
News score 5 or more
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88
Q

How much glucose should be given in IV fluids for maintenance?

A

50-100g per day

89
Q

In which patients might you consider prescribing less IV fluid for maintenance?

A 
Old
Frail
Renal impairment 
Cardiac failure 
Malnourished with risk of refeeding syndrome
90
Q

In which patients should you seek expert help for their fluid prescription?

A 
Gross oedema
Severe sepsis 
Hyponatraemia or hypernatraemia 
Renal, liver and/or cardiac impairment 
Post operative fluid retention and redistribution 
Malnourished and refeeding issues
91
Q

Why can resuscitation with crystalloid solution lead to pulmonary oedema?

A

Dilutes plasma proteins so reduces plasma oncotic pressure

92
Q

How do you calculate a patients ideal body weight from their height?

A

Male: (Height in cm - 154) X 0.9) + 50
Female: same equation but + 45.5 instead of 50

93
Q

What fluid should be given to someone with acute hyponatraemia and neurological symptoms?

A

Bolus doses of hypertonic saline (1.8%)
Assess clinical response
Remeasure Na

94
Q

A 55 year old male presents with a left testicular swelling. On examination he has a large left testis of approximately 30 ml in volume. The mass is smooth, tender, fluctuant and transilluminates. What is the likely cause?

A

Hydrocoele

95
Q

A 32 year old male presents after recently noting a lump in the testis. On examination there is a non tender 2cm solid nodule within the testis. What is the likely diagnosis?

A

Seminoma (troops and sergeants: troops are 18-25, sergeants are usually 30 plus)

96
Q

A 40 year old male presents with a lump in the shaft of his penis. On examination there is a non tender, fibrotic nodule in the left lateral half of the penis of 1.5cm diameter. What is the likely diagnosis? What is it associated with?

A

Peyronie’s disease - fibrotic process in the tunica albuginea
Associated with penile curvature and pain
Can be associated with dupuytrens contracture

97
Q

Why can a ruptured AAA mimic Ureteric colic?

A

Pooling of blood from the aorta into the retroperitoneum

98
Q

What are risk factors for testicular torsion?

A 
Age under 25
Neonate 
Bell clapper deformity 
Trauma 
Exercise 
Intermittent testicular pain 
Undescended testicle 
Cold weather
99
Q

How do you calculate corrected calcium?

A

Serum calcium + 0.8 X (4- serum albumin)

100
Q

What is prehns sign?

A

Negative Prehn’s sign: no pain relief with lifting affected testicle, testicular torsion which is a surgical emergency
Positive Prehn’s sign: pain relief with lifting affected testicle, which points towards epididymitis

101
Q

Why is a scrotal biopsy not a good idea for a patient with a suspected testicular tumour?

A

Tunica albugenia is a natural barrier to local mets so should not be compromised
Lymph drainage of scrotal skin is different to testicle so don’t want to risk spreading it

102
Q

What are risk factors for testicular cancer?

A 
Cryptorchidism
Gonadal dysgenesis 
FH of testicular cancer
Personal hx of testicular cancer
Testicular atrophy
White ethnicity
Chemical carcinogens
Low sperm count
Rural residence 
Higher SES 
Inguinal hernia 
Genetic abnormality of chromosome 12
103
Q

What investigations might you order in a suspected testicular tumour?

A 
USS with Doppler
CT abdo pelvis
Serum beta hCG >0.7
Serum alpha fetoprotein >25
Serum LDH >25
CXR - mets
104
Q

During what week of development does the processus vaginalis form?

A

12th

105
Q

How long is the inguinal canal in adults?

A

4-6 cm

106
Q

What are the boundaries of the inguinal canal?

A

Posterior wall: transversalis fascia lateral, conjoint tendon medial
Anterior wall: internal oblique lateral, aponeurosis of external oblique
Roof: internal oblique and transversus abdominis muscles
Floor: inguinal ligament and lacunar ligament medially

107
Q

What are the boundaries of hesselbachs triangle?

A

Lateral: inferior epigastric artery
Medial: rectus abdominis muscle
Inferior: inguinal ligament

108
Q

What are contents of the inguinal canal in males and females?

A

Male: spermatic cord, ilioinguinal nerve
Female: round ligament of uterus, ilioinguinal nerve, genital branch of genitofemoral nerve

109
Q

What is the contents of the spermatic cord?

A

3 fascia: external spermatic fascia, cremasteric muscle and fascia, internal spermatic fascia
3 arteries: testicular, vas deferens, cremasteric
3 nerves: sympathetics, ilioinguinal, genital branch of genitofemoral nerve
3 structures: vas deferens, pampiniform plexus, processus vaginus

110
Q

What is the femoral sheath?

A

Extension of transversalis and iliopsoas fascia
Encloses proximal parts of femoral vessels
3-4cm inferior to inguinal ligament

111
Q

What are the borders of the femoral canal?

A

Anterior: inguinal ligament
Posterior: pectineal ligament
Medial: lacunar ligament
Lateral: femoral vein

112
Q

What is cloquets node?

A

Lymph node in inguinal region

Part of deep inguinal node group

113
Q

Describe pathway of sperm from seminiferous tubule to ductus deferens

A

Seminiferous tubule to straight tubule to rete testis to efferent ductules to caput epididymis to corpus epididymis to cauda epididymis to ductus deferens

114
Q

What is the epididymis?

A

Posterior border of testis
Composed of 3 parts: head, body and tail
Allows space for storage and maturation of sperm

115
Q

What is the blood supply to the testes? Describe their path

A

Testicular arteries which arise from abdominal aorta just inferior to renal arteries
Travel retroperitoneally, cross over ureters and external iliacs to pass through deep inguinal ring

116
Q

Describe venous drainage of the testes

A

Network of 8-12 veins called pampiniform plexus
Veins converge superiorly forming a testicular vein at deep inguinal ring
Right enters IVC, left drains into left renal vein

117
Q

Where does lymph drain to from the testes?

A

Pre aortic nodes

118
Q

Give some ddx for inguinal swelling

A 
Inguinal hernia 
Femoral hernia 
Hydrocoele 
Cryptorchidism
Lymphadenopathy 
Saphenous varix
Femoral artery aneurysm
Psoas abscess 
Lipoma
Sebaceous cyst
119
Q

Give some ddx for scrotal swelling

A 
Testicular tumour 
Hydrocoele 
Epididymal cyst 
Spermatocoele
Varicocoele 
Inguinoscrotal hernia
120
Q

What questions are important in the assessment of a scrotal lump?

A

When first noticed
Is it changing
Is it lump reducible
What symptoms are present: Pain, Systemic symptoms, GI/GU disturbances
How was it noticed: Precipitating activity, Recent illness

121
Q

What are important parts of an examination of a scrotal lump?

A 
Position shape and size   
Temperature 
Tenderness 
Composition: solid/fluid/gas 
Consistency 
Fluctuations  
Translucency 
Pulsatility  
Reducibility/cough impulse 
Relations to the surrounding structures
Regional lymph nodes 
Hernia test: Standing and lying, Getting above it, Cough impulse, Reducibility and control  
Associated structures: Testes, Lymph nodes
Special test: Trans illumination
122
Q

What investigations can be performed for a scrotal lump?

A

Ultrasound: for early hernias not so reliable
Doppler/duplex: useful for testes/vascular assessment
CT/MRI:mdeeper anatomy
Laparoscopy

123
Q

What can be causes of inguinal lymphadenopathy?

A

Primary: Lymphoma
Secondary: Malignant, Benign
Physiolgical response to infection

124
Q

What would do to manage a patient with inguinal lymphadenopathy?

A

Exclude inflamatory cause: Abx/observe

Exclude malignancy: Biopsy, FNAC/Open

125
Q

What are some causes of a saphenous varix?

A

Idiopathic
Pregnancy
Pelvic mass
Dvt

126
Q

What examination feature would make it clear that the patient has a saphenous varix?

A

Disappears on lying flat

127
Q

What should be done to diagnose a saphenous varix?

A

Doppler/duplex

128
Q

What is the treatment for a saphenous varix?

A

Endovascular surgery

129
Q

What are differences between true and false femoral artery aneurysms?

A

True: Pulsatile, Associated with other aneurysmal diseases –AAA, popliteal
False: Secondary to punctures

130
Q

What is used to diagnose a femoral artery aneurysm?

A

Duplex scan

131
Q

What can be done to treat a true and false femoral artery aneurysm?

A

True: repair if indicated, >2/3 cm
False: surgical excision/repair

132
Q

What is cryptorchidism?

A

Absence of one or both testes from the scrotum

133
Q

What are problems with cryptorchidism?

A

Subfertility/sterlity
Torsion
Trauma
Malignancy

134
Q

By what age should both testes be descended?

A

2 years

135
Q

What would you do to investigate a patient who you suspect has a testicular tumour?

A

CT chest abdo pelvis

Tumour markers

136
Q

What are the different classifications of hydrocoele?

A

Vaginal: confined to scrotum (distends tunica vaginalis)
Congenital: communicating with peritoneal cavity
Infantile: extending upwards to internal ring
Hydrocele of the cord: confined to the cord

137
Q

What can causes of a hydrocoele?

A

Congenital: communicating
Reactive: tumour, infection, trauma
Idiopathic

138
Q

What investigations and management should be done for a hydrocoele?

A

USS/exclude malignancy
Aspiration not helpful
Surgery

139
Q

What is a varicocoele?

A

Dilation of pampiniform plexuses of veins

140
Q

On which side is a varicocoele most likely to occur?

A

Left

141
Q

What is a potential long term consequence of a varicocoele?

A

Infertility

142
Q

How does a varicocoele usually present?

A

Painless lump
Bag of worms
May reduce on lying down

143
Q

What investigations and management should be done for a varicocoele?

A

USS: Exclude sinister cause

Ligation at deep ring

144
Q

What can cause epididymo orchitis?

A 
Gonorrhea  
Chlamydia  
E coli (most common)
Mycobacterium tuberculosis
Amiodarone
145
Q

What time frame do you have to save a testicle which has undergone torsion?

A

6 hours

After 12 hours, the testis cannot be salvaged

146
Q

What is the treatment for testicular torsion?

A

Orchidopexy bilaterally

147
Q

What is a hernia?

A

Protrusion of an organ or part of anorgan through a defect in wall of the cavity normally containing it

148
Q

What are the different clinical classifications of hernias?

A

Reducible: hernia can be easily manipulated back into place
Irreducible or incarcerated: this cannot usually be reduced manually, adhesions form in hernia sac
Obstructed: With features of bowel obstruction
Strangulated: compromise to blood supply of involved bowel

149
Q

What does inguinal hernia repair aim to achieve?

A

Strengthen posterior inguinal wall with mesh

150
Q

Where anatomically are you likely to find a femoral hernia?

A

Neck of the sac is below and lateral the pubic tubercle

151
Q

What is a femoral hernia most likely to contain?

A

Omentum

152
Q

Name 3 complications of mesh hernia repair

A

Recurrence
Mesh infection
Haematoma formation
Seroma formation

153
Q

A 45-year-old man had developed a direct inguinal hernia several months after having an emergency appendectomy. The examining doctor linked the cause of hernia to accidental nerve injury that happened during appendectomy and weakened the falx inguinalis. Which nerve had been injured?

A

Ilioinguinal nerve

154
Q

A 40 years old gentle man presents with painless lump in his scrotum and weight loss. Clinical examination reveals enlarged hard non tender right hemiscrotum. Inguinal lymph nodes were
not enlarged. No cough impulse could be demonstrated. Most likley diagnosis

A

Seminoma

155
Q

A patient with a suspected seminoma has non palpable inguinal lymph nodes. This patient is unlikely to have metastatic disease, true or false? And why?

A

False
Intraabdominal origin, testis have lymph drainage to the lumbar lymph nodes. Thus, infection of the epididymis or testicular carcinoma does not typically cause enlarged inguinal lymph nodes

156
Q

What structures are at risk during a femoral hernia repair ?

A

Femoral vein

Accessory obturator artery

157
Q

What are management steps for testicular torsion?

A 
USS scrorum  
Analgesia and reassure  
Abx  
CT KUB  
Organize theatre to explore his scrotum
158
Q

What measurements are required for diagnosis of CKD?

A

EGFR x2 and albumin creatinine ratio

159
Q

What is the management for CKD?

A

Identify/treat cause
Medication
Control BP
ACE if proteinuria

160
Q

What is Peyronie’s disease?

A

Fibrosis in plantar fascia and penis

161
Q

Why does the pain of a ruptured AAA mimic that of ureteric colic?

A

Pooling of blood from aorta into retroperitoneum

162
Q

Give 3 drugs which may have to be stopped in AKI due to increased toxicity, but don’t usually worsen the AKI themselves

A

Metformin
Lithium
Digoxin

163
Q

Give 3 drugs which should be stopped in AKI as they may worsen renal function

A 
NSAIDs
Aminoglycosides 
ACE inhibitors
ARBs
Diuretics
164
Q

What are treatments for hyperkalaemia?

A 
IV sodium gluconate 
Insulin dextrose infusion
Nebulised salbutamol
Calcium resonium
Loop diuretics
Dialysis
165
Q

What are normal maintenance requirements for fluids and electrolytes?

A

Water: 25-30 ml/kg/day
Sodium, potassium and chloride: up to 1 mmol/kg/day
Glucose: 50-100 g/day

166
Q

What are signs and symptoms of salt and water retention?

A 
Breathlessness
Cough
Pink frothy sputum
Chest pain
Oedema
Tachycardia 
High BP
Raised JVP
Gallop rhythm 
Crackles 
Pleural effusion 
Ascites
167
Q

What are signs and symptoms of salt and water depletion?

A 
Malaise 
Weakness
Dizziness
Syncope
Skin tugor down
Sunken eyes
Tachycardia
Postural BP drop
Hypotension 
Urine output
168
Q

What are causes of hyperkalaemia?

A

Excess intake: IV or oral, dietary
Excess production: haemolysis, rhabdomyloysis, tumour lysis, crush injury, burns
Redistribution: acidosis, insulin deficiency, b blockers, digoxin
Diminished excretion: AKI, CKD, Addison’s, Renal tubular acidosis, NSAIDs, cyclosporine, ACEi, ARB, spironolactone

169
Q

What are the clinical manifestations of hyperkalaemia?

A

Cardiac arrhythmia and arrest

Ascending muscle weakness

170
Q

How do you manage hyperkalaemia?

A

Calcium gluconate, insulin and dextrose, salbutamol nebs, sodium bicarbonate, calcium resonium, haemodialysis

171
Q

What are causes for hypokalaemia?

A

Decreased intake
Gastro losses: vomiting, diarrhoea, draining tubes, laxatives
Urinary losses: diuretics, conns, hypomagnesaemia
Increased translocation into cells: beta agonists, insulin excess, alkalosis
Increased sweat loss
Dialysis

172
Q

What are clinical manifestations of hypokalaemia?

A 
Severe muscle weakness
Muscle cramps
Resp failure
Ileus 
Cardiac arrhythmia and ECG abnormalities
173
Q

What ECG changes are present in hypokalaemia?

A 
Small or absent t waves
Prominent u waves
First or second degree AV block
Slight st depression
QT prolongation, can induce torsades and VF
174
Q

What is the treatment for hypokalaemia?

A

Supplemental potassium at a rate of no more than 20 mmol per hour and monitor cardiac rhythm

175
Q

What are causes of hyponatraemia?

A

Isotonic: hyperproteinaemia, hyperlipidaemia
Hypotonic hypovolaemic: dehydration, diarrhoea, vomiting, diuretics, ACEi, nephropathy, mineralocorticoid deficiency
Hypotonic euvolaemic: SIADH, post op, hypothyroidism, psychogenic polydipsia
Hypervolaemic: congestive heart failure, liver disease

176
Q

What is acute hyponatraemia?

A

Drop in sodium more than 10 mmol/L in 24 hrs

177
Q

What are symptoms of hyponatraemia?

A 
Nausea and vomiting
Confusion
Headache
Cardio respiratory distress
Abnormal somnolence
Seizures 
Coma
178
Q

How do you manage severe symptoms of hyponatraemia?

A

3% normal saline, restrict fluids if hypervolaemic
Monitor sodium levels every 4 hours
Aim for maximum increase 8 mmol/24 hrs and 8 mmol next 24 hrs
Stop infusion if sodium 130 or more than 8mmol increase

179
Q

What is central pontine myelinolysis?

A

Rapid correction of hyponatraemia

Leads to coma and paralysis

180
Q

What are causes of hypernatraemia?

A 
Water deficient 
Loss of thirst mechanism 
GI loss
Loop diuretic
Diabetes insipidus 
Hyperglycaemic hyperosmolar non ketotic coma
181
Q

What investigations should be done for hypernatraemia?

A

Glucose
Serum osmolality
Urine osmolality
If DI suspected: desmopressin test

182
Q

What is the treatment for diabetes insipidus?

A

Treat cause

Replace fluid - 0.45% saline 5% dextrose

183
Q

What is a normal anion gap?

A

8-16

184
Q

How do you calculate anion gap?

A

Sodium - (chloride and bicarbonate)

185
Q

What are some causes of a raised anion gap?

A 
Methanol
Uraemia 
DKA
Isoniazid 
Lactic acidosis 
Ethanol
Renal failure
Salicylates
186
Q

What causes of metabolic acidosis would result in a normal anion gap?

A

Renal tubular acidosis
Addison’s
Acetazolamide
Diarrhoea

187
Q

What is management for severe metabolic acidosis?

A

Check glucose for DKA
Measure creatinine and urine output
Oral sodium bicarbonate/IV
Low gcs/encephalopathy - dialysis

188
Q

What are some respiratory causes for respiratory acidosis?

A

Obstructive sleep apnea
Obesity hypoventilation
Respiratory depression
Respiratory muscle weakness - Guillain barre, chest wall abnormality

189
Q

What are some causes of metabolic alkalosis?

A

Vomiting
Conns
Cushing’s
Excess alkali ingestion

190
Q

What is the AKIN criteria for AKI?

A

Stage 1: creatinine raised 1.5-2x, urine

191
Q

What are potential complications of AKI?

A

Hyperkalaemia
Pulmonary oedema
Acidosis
Uraemia

192
Q

What are the principles of managing AKI?

A 
Fluid management 
Manage complications 
Look for and treat cause
Manage medicines 
Fluid balance assessment
Daily U and Es 
Nephrology specialist input
193
Q

What are some systemic causes of haematuria?

A

Coagulation disorders
Sickle trait
Vasculitis
Sub-acute bacterial endocarditis

194
Q

What are some renal causes of haematuria?

A 
Infection
Glomerular disease
Malignancy
Infarction
Trauma 
Cystic disease 
Vascular malformations
195
Q

What are some Ureteric causes of haematuria?

A

Calculi

Malignancy

196
Q

What are some bladder causes of haematuria?

A

Infection
Malignancy
Calculi

197
Q

What are some outflow tract causes for haematuria?

A

Prostate malignancy
Trauma
Prostatitis

198
Q

What investigations might you do for haematuria?

A 
Urine dip and microscopy culture and sensitivity 
PSA
HB electrophoresis 
FBC, U and Es, coag studies
PCR/ACR
Ultrasonography
CT-U
MRU
Cystoscopy 
Renal biopsy
199
Q

What cell type does a renal cell carcinoma originate from?

A

Proximal renal tubular epithelium

200
Q

What factors increase the risk of renal cell carcinoma?

A 
PCKD
Middle aged man
Tuberous sclerosis 
Smoking
Von Hippel Lindau syndrome
201
Q

What are symptoms of a renal cell carcinoma?

A

Haematuria
Loin pain
Abdominal mass

202
Q

What are risk factors for bladder cancer?

A 
Smoking
Age >55
Pelvic radiation
Systemic chemotherapy
Male
Chronic bladder inflammation
FHx
Transitional cell: Exposure to aniline dyes in printing and textile industry, Rubber manufacture, Cyclophosphamide
Squamous cell: Schistosomiasis,BCG treatment
203
Q

What are symptoms of bladder cancer?

A

Dysuria
Presence of risk factors
Painless haematuria

204
Q

What stage is a bladder tumour if it has invaded into the muscle?

A

At least 2

205
Q

What can cause acute urinary retention in a man?

A 
BPH
Meatal stenosis
Paraphimosis
Penile constricting bands
Phimosis
Prostate cancer
Bladder calculi, Bladder cancer, Faecal impaction, GI/ retroperitoneal Ca, Urethral strictures, Foreign bodies, Stones
206
Q

What can cause acute urinary retention in a woman?

A

Prolapse (cystocele, rectocele, uterine)
Pelvic mass (gynaecological malignancy, uterine fibroid, ovarian cyst)
Retroverted gravid uterus
Bladder calculi, Bladder cancer, Faecal impaction, GI/ retroperitoneal Ca, Urethral strictures, Foreign bodies, Stones

207
Q

What drugs can cause acute urinary retention?

A 
Anticholinergics
Opioids and anaesethetics
Alpha adrenoceptor agonists
Benzo 
NSAID
Calcium channel antagonist
208
Q

What drugs can lead to chronic urinary retention?

A

Antispasmodics
Antihistamines
Anticholinergics
Botulinum toxin

209
Q

What factors increase the risk of prostate cancer?

A

Increasing age
Obesity
Afro-Caribbean ethnicity
Family history: around 5-10% of cases have a strong family history

210
Q

What can be symptoms of prostate cancer?

A 
Bladder outlet obstruction
LUTS
Haematuria
Haematospermia
Pain: back, perineal, testiular
DRE: asymmetrical hard nodular enlargement and loss of median sulcus
211
Q

What investigations can be done for prostate cancer?

A 
PSA (normal in 30% of cancers)
TRUSS
TRUSS biopsy
X-rays
Bone scan
CT-MRI
212
Q

What are treatment options for prostate cancer?

A

Watchful waiting
Radical prostatectomy
Radiotherapy
Hormonal therapy

213
Q

What is IgA nephropathy?

A

Mesangioproliferative glomerulonephritits
Commonest cause of glomerulonephritits worldwide
Mesangial deposition of IgA complexes

214
Q

How might IgA nephropathy present?

A

Young male
Recurrent macroscopic haematuria
Associated mucosal infection: URTI
Renal failure

215
Q

What is trousseau’s sign?

A

Hypocalcaemia, carpal spasm occurs after inflating a blood pressure cuff above systolic pressure

216
Q

What is chvosteks sign?

A

Spasm of facial muscles following tapping over facial never seen in hypocalcaemia

217
Q

What is L’Hermitte’s sign?

A

Multiple sclerosis, lesion of dorsal columns of spinal cord at cervical level
On flexing neck, shooting sensation down spine

218
Q

What is kernigs sign?

A

Pain and resistance to knee extension when hip is flexed to 90 degrees and patient lying supine. Sign of meningism

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