Urology and Endocrine Flashcards
core urinary symptoms
frequency nocturia urgency incontinence incomplete voiding visceral pain haematuria dysuria
what is phimosis
foreskin cannot be pulled back
what is paraphimosis
when foreskin cannot be reduced
what are some obstructive symptoms that can occur in LUT
poor flow hesitancy intermittency post micturition dribbling incomplete voiding
what hormone fuels BPH?
testosterone
what does early, terminal and continuous haematuria indicate about the source
early - urethral/piping
terminal - prostate
continuous - bladder
what are some possible causes of haemturia
BPH cancer infection stones trauma
what is enuresis?
unconscious voiding
what is the typical age for testicular torsion presentation
10-11
what could a scrotal mass be
hernia torsion tumour trauma varicocele cyst
what endocrine dysfunction manifests in CKD?
RAAS - heart/BP
EPO - anaemia
Vit D - bone
what is usually included in a U n E panel
sodium potassium eGFR creatinine urea
low urea is a cause of concern - true or false
false
what can high urea suggest?
acute or chronic kidney failure
or shock
or dehydration
how should creatinine be interpreted?
against the patients demographic’s baseline.
big muscular patients have high creatinine baseline.
oppo is true
what two markers are best for indicating kidney function
creatinine and eGFR
symptoms of hypernatraemia
lethargy, weakness
confusion
coma/seizures
what can cause hypernatraemia
dehydration
diabetes insipidus
iatrogenic (too much IVT)
symptoms of hyponatraemia
nausea malaise headache irritability confusion muscle weakness
what ECG changes can be seen with hyperkalaemia
tented T wave
flattening of P waves
progressive lengthening of PR intervals/QRS
common causes of hyperkalaemia
acute/chronic kidney failure
drugs (ACEI/ARBs)
Diabetic ketoacidosis (T1DM)
addision’s disease
common causes of hypokalaemia
diuretics
V and D
cushings/steroid use
symptoms of hypokalaemia
muscle weakness hypotonia hyporeflexia cramps palpitations constipations
what kind of antibiotics can cause acute kidney injury
aminoglycosides e.g. gentamicin
what are some pre-renal, renal and post renal causes of acute kidney injury
absolute or relative loss of fluid
renal disease
drugs
urinary tract obstruction
symptoms of acute kidney injury
fatigue nausea confusion dehydration reduced urine output
causes of chronic kidney disease
hypertension diabetes polycystic kidney disease chronic urinary tract obstruction primary or secondary glomerular disease
what factors should be considered in management of CKD
BP control
anaemia
vitamin D
modify risk factors
describe fibroadenosis,
Fibroadenosis is fibrocystic disease
Rubbery and bilateral.
Pain and lumpiness Fluctuates with period cycle
describe a fibroadenoma
Hyperplasia of terminal duct lobules
Firm, non-tender and highly mobile lump (untethered)
usually <30 YO
fibroadenomas have no increase in breast cancer link - true or false?
true
describe a breast cyst
fluid filled sacs in breast tissue
smooth firm lumps
soft and fluctuant or hard and painful
common 30-60 YO
2 types of breast abscess
lactational abscess
non-lactational abscess
describe a non-lactational breast abscess
usually under areola, nipple inversion associated. common in young female smokers
symptoms of breast abscess
erythema, pain, swelling
symptoms of breast cancer
breast/axilla lump discharge skin changes thickened tissue change in size
modifiable risk factors of breast cancer
OCP obesity breast feeding alcohol HRT
how to conduct a breast exam?
intro - chaperone
look - 4 hand positions
palpation - hand behind head, check axillary and supraclavicular lymph nodes
what does a patients HbA1C tell u?
three month average plasma glucose concentration
what should a normal HbA1C reading be?
<42 mmol/mol
what is a diabetic HbA1C reading?
48+ mmol/mol
what are 3 possible diagnostic criteria for DM?
random glucose >11.1 w/ symptoms
2x random glucose >11.2 w/o symptoms
HbA1C >48 or 6.5%
what are some possible secondary causes of diabetes
acromegaly
cushing’s
haemochromatosis
pancreatitis
macrovascular effects of diabetes
CVS - angina, MI, CHF
CBVS - stroke, TIA
microvascular effects of stroke
eyes - retinopathy, glaucoma, cataracts
kidneys- nephropathy
PNS - peripheral neuropathy
PVD - absent foot pulse, ischaemic skin changes, gangrene
what is the normal range for blood glucose
<7.8
stages of diabetic retinopathy
background retinopathy - micro aneurysm
pre-proliferative retinopathy - hard exudates, soft exudates
proliferative retinopathy - neovascularisation and possible hemorrhage
what is the surgical sieve
VITAMIN C D E F
vascular inflammatory/infection trauma autoimmune Metabolic Iatrogenic Neoplastic
Congenital
Degenerative
Endocrine/environment
Functional
1 unique feature of quinsy
Difficulty opening mouth
Describe the partitions of the neck 1 - 6
1 - under the mandible 2 - top of SCM (angle of jaw) 3 - middle of SCM 4 - bottom of SCM to clavicle 5 - posterior triangle 6 - tracheal region
What are some dysfunctions one can have in ENT?
Breathing
Swallowing
Voice
Endocrine
How to tell if a lump is a thyroglossal cyst
Will move when tongue is protruded
Why does a thyroglossal cyst move with protrusion of the tongue
Cyst attached to hyoid bone, tongue attached to hyoid bone.
Describe the features of a branchial cyst
Well defined anterior border, but undefined posterior and superior borders because its under SCM and jaw
Features of a thyroglossal cyst? Signs and site?
Midline neck lump
Painless
Smooth
Cystic
Moves on swallowing and protrusion of tongue
Around the region of the hyoid bone
Features of a branchial cyst
Smooth
Slowly enlarging mass
+/- fistula
What can cause swelling of the parotid gland?
Mumps
Where would a parapharyngeal abscess be located?
Behind the jaw
Symptoms of a parapharyngeal abscess?
Fever
Sore throat
Odynophagia
Neck swelling
Features of a malignant lymphadenopathy
Hard
Tethered to skin
What should not be forgotten when presenting with ear pain?
The throat!
How does candidiasis of the throat look like
Yellowy white reddish patches of the pharynx
indications for a PR exam
constipation cauda equina syndrome hemorrhoids prostatic conditions rectal cancer
symptoms of BPH
>storage increased frequency urgency nocturia incontinence
>voiding hesitency intermittency incomplete voiding weak flow dribbling
> post-micturition
dysuria
urinary retention
bladder pain
a urinary catheter is the first line for incontinence - true or false
false - used a “condom” type tube
indications for urinary catheter
relieve urinary retention
monitor urine output
collect urine sample
bladder irrigation
what factors are used to diagnose acute kidney injury?
serum creatinine and urine output
what are the risk factors for acute kidney injury
age >75 CKD cardiac failure PVD chronic liver disease diabetes sepsis drugs fluid imbalance hx of urinary symptoms
what is the criteria for stage 3 AKI
> 3x serum creatinine baseline increase
<0.3 mL/kg/hr for 24hr OR anuria for 12 hr
signs and symptoms of CKD
anaemia GI disturbance (anorexia, NVD) polyneuropathy CNS dysfx CVS dysfx oedema bone dysfx
how to differentiate acute and chronic kidney failure
previous sCr to determine pattern
duration of symptoms
small kidney on U/S
what factors are used in the staging of CKD
eGFR and albumine-creatinine ratio
what is the duration criteria for CKD
3 months
which benign breast lumps are not associated with pain
fibroadenoma
common age for fibroadenoma
<30
benign breast lumps associated with period cycle
fibrocystic disease
fibroadenoma
breast cyst
common ages for fibrocystic disease
20-50 (premenopausal)
fibrocystic disease is associated with a discharge true or fals
true
common locationfor fibrocystic disease
bilateral, multiple lumps
texture of fibroadenoma lump
firm/ rubbery
which breast lump is the most mobile
fibroadenoma
how does fat necrosis in the breast arise
trauma
what associated symptoms come with breast abscess
inflammatory, infection - redness, swelling, pain
what causes diabetic ketoacidosis
lack of insulin leads to rise in blood glucose and metabolism of fatty acids yielding high ketone bodies.
signs and symptoms of DKA
Nausea and vomiting thirst polyuria abdominal pain tachycardia and hypotension kussmaul respiration pear drops scent reduced GCS dehydration hyperglycaemia cerebral edema
Main aims on how should a patient with DKA be treated
rehydrate
give insulin
potassium
What is hyper osmolar hyperglycaemic state
Happens in uncontrolled type 2 DM
High blood glucose, dehydration, high blood osmolality.
Little to no ketones
Signs of hyper osmolar hyperglycaemic state
Dehydration
Reduced GCS
Insulin levels in HHS
Low, but sufficient to prevent ketogenesis. But no enough to prevent hyperglycaemia
What often precipitates HHS
Infection - pneumonia
Blood biochemical differences between DKA and HHS
HHS has higher bicarb, urea and blood glucose.
High pH also cos lower ketones.
Main aims of treatment for HHS
Rehydrate.
Some insulin
Replace lost electrolytes
Complications of insulin therapy
Hypoglycaemia
Lipohypertrophy at injection sites
Insulin resistance
Weight gain
2 classifications of symptoms in hypoglycaemia
Adrenergic
Neruglycopaenic
Adrenergic symptoms in hypoglycaemia
Sweating Shaking Pallor Anxiety Hunger Abdominal discomfort Dilated pupils N&V Palpitations
Neuroglycopenic symptoms in hypoglycaemia
Reduced GCS Confusion Impaired judgement Seizures Memory loss Lethargy Blurred vision Slurred speech Ataxia Paraesthesia and paralysis Coma
What can be found in a typical hypobox
Sugary drinks
Dextrose tablets
IV glucose
Dextrose gel
What can cause secondary diabetes
Acromegaly
Cushing’s syndrome
Haemochromatosis
Pancreatitis
What is the most common cause of blindness in people under 65?
Diabetes
What causes diabetic retinopathy
High blood glucose causing damage to retinal vessels
Stages of diabetic retinopathy
Non-proliferative
Pre-proliferative
Proliferative
Advanced retinopathy
Features of non-proliferative diabetic retinopathy
Microaneurysms (dot haemorrhages)
Blot haemorrhages
Hard exudates (protein + lipid)
What causes hard exudates in non-proliferative retinopathy
Breakdown of blood-retina barrier causing lipid and proteins to leak into the retina
Description of hard exudates in diabetic retinopathy
Bright yellowish color
Irregular outline
Sharply defined margin
Features in pre-proliferative diabetic retinopathy
Cotton wool spots
Venous loops and beading
Intraretinal microvascular remodelling
What causes cotton wool spots in diabetic retinopathy
Edema from retinal infarcts
Description of cotton wool spots in diabetic retinopathy
Greyish white
Indistinct margins
Dull matte surface
Difference in appearance between cotton cool spots and hard exudates in diabetic retinopathy
Hard exudates are bright yellow and shiny
Cotton wool spots are greyish white and dull
What causes venous loops and beading in diabetic retinopathy
Retinal ischaemia
Where do you find intraretinal microvacular remodelling in diabetic retinopathy
Borders of non-perfused retina
Features of proliferative diabetic retinopathy
Pre-retinal neovascularisation
Haemorrhages of neovessels
Vitreous haemorrhage
Features of advanced diabetic retinopathy
Retinal fibrosis
Retinal detachment
Features of maculopathy in diabetic retinopathy
Maculo edema
Perimacular hard exudates
What causes diabetic nephropathy?
Persistent glycosaemia causes reactive oxygen species and glycation products. Damaging glomeruli and proteinuria. Eventually kidney failure occurs as damage spreads.
How to diagnose diabetic nephropathy?
Urine albumin
Starts off as microalbuminuria
Then more albumin leaks through eventually leading to proteinuria detectable by dipsticks.
What causes diabetic neuropathy
Occlusion of blood supply to peripheral nerves and/or accumulation of glucose products disrupting nervous function
What is the first stage of diabetic neuropathy
Symmetrical sensory neuropathy
Describe the progression of diabetic sensory neuropathy
Starting in feet, loss of vibration sense, pain, temperature. Followed by proprioception and balance.
Complications of diabetic sensory neuropathy
Loss of pain sensation leads to unrecognised trauma, ulceration and neuropathic arthropathy like Charcot’s joint
What causes charcots joint
Loss of pain sensation leads to abnormal mechanical stress on the joints, accumulation of which leads to joint deformities like large bony swellings
What does motor nerve neuropathy in diabetics lead to
Muscle wasting
Distortion of feet with high arches and clawed toes
Describe acute painful neuropathy in diabetes
Burning crawling pain in lower limbs, worst at night and exacerbated by pressure
What is mononeuritis and mononeuritis multiplex in diabetics?
Radiculopathy involving one or more nerve roots causing pain along a dermatome/myotome.
What is a common diabetic mononeuritis?
Carpal tunnel
What is the most common cranial mononeuritis in diabetes
3rd and 6th nerve palsy
Describe 3rd and 6th nerve mononeuritis multiplex in diabetics
Unilateral pain, ptosis and diplopia - no change in pupillary function.
What is it called when a diabetic has marked quadriceps muscles wasting with pain and diminished or absent knee reflexes?
Diabetic amyotrophy
What systems are commonly affected in diabetic autonomic neuropathy
Cardiovascular
GI
Bladder
Penile
What is the effect of diabetic autonomic neuropathy on the CVS
Resting tachycardia Loss of sinus arrhythmia Postural hypotension Peripheral vasodilation - warmth in feet Bounding pulse
What is sinus arrhythmia
Physiological response to the respiratory cycle causing increase or decrease vagal tone leading to change in heart rate
What can prolonged diarrhea in a diabetic indicate?
Autonomic neuropathy in the GI system
What will autonomic neuropathy in diabetes do to a patient’s sex life
Males will get erectile dysfunction
What signs are indicative of someone at risk to diabetic feet
Neuropathic signs
Vascular disease signs
What vascular disease signs can be found on someone at risk to diabetic feet
Thin skin Hair loss Bluish discoloration of skin Reduced skin temperature Absent foot pulses
What should be considered in someone at risk to diabetic feet
Regular chiropody checks
Special shoes
Daily feet inspection
Avoid heat sources
Why should regular subcutaenous insulin injection sites be rotated
Prone to lipohypertrophy at injection site
What is the biggest risk to the patient when having insulin infusions
Hypoglycaemia
Having a goitre is indicative of thyroid pathology - T or F?
False.
What types of goitres are there
Diffuse
Multinodular
Singular nodule
What does a goitre associated with lymphadenopathy indicate?
Malignancy
What can cause a diffuse goitre
Overactive or underactive thyroid Iodine deficiency Graves disease Hashimoto’s disease Acute viral thyroiditis
What investigations should be done on a patient with a goitre
Bloods - thyroid function tests
Imaging - U/S
FNA
Which is the biologically active hormone, T3 or T4
T3
In a hyperthyroid patient, what symptoms only occur in Graves disease
Exophthalmos and opthalmoplegia (restricted eye movement)
Thyroid acropachy
What is seen in thyroid acropachy
Hand swelling
Clubbing
Perioesteal new bone formation
3 most common causes of hyperthyroidism
Graves
Toxic multinodular goitre
Toxic adenoma
Biochemical picture of hyperthyroidism
Low TSH
High T4 and T3
Symptoms of hyperthyroidism
Weight loss Increased appetite Irritability Tremor Heat intolerance Diarrhea Eye symptoms Period disturbance Sweating Palpitations
Signs of hyperthyroidism
Tachycardia Lid lag Warm vasodilated peripheries Tremor Hyperkinesis Exopthalmos Goitre bruit Weight loss Pretibial myxoedema Palmar erythema
Common causes of hypothyroidism
Autoimmune (hasimotos or thyroid atrophy)
Iatrogenic
Drug induced
Iodine deficiency (endemic)
Some medication that can cause hypothyroidism
Carbimazole
Lithium
Amiodarone
Interferon
What to look for in suspected autoimmune hypothyroidism
Antibodies
Biochemical markers of hypothyroidism
High TSH
Low T3, T4
Symptoms of hypothyroidism
Weight gain Lethargy Cold intolerance Poor appetite Goitre Dry brittle hair Dry skin Constipation Period disturbance Low moods
Signs of hypothyroidism
Dry thin hair
Bradycardia
Dri skin
Slow relaxing reflexes
How do reflexes change in hypothyroidism
Slow relaxing reflexes.
Initial reflex is normal, but muscle will be slow to relax.
What kind of goiter would someone with hasimotos classically present with
Hard non-tender
What is addison’s disease
Primary hypoadrenalism -> loss of adrenal gland function
What is the difference between primary, secondary and tertiary hypoadrenalism
Primary = adrenal gland problem
Secondary = pituitary gland problem
Tertiary = hypothalamus problem
What is the HPA axis?
Hypothalamus makes CRH which stimulates anterior pituitary to make ACTH which stimulates adrenal glands to make cortisol.
Clinical features of addison’s disease
Lethargy Depression Anorexia Weight loss Postural hypotension Hyperpigmentation In women, vitiligo and body hair loss
Why is hyperpigmentation seen in addison’s diseaser
Stimulation of melanocytes by excess ACTH
Where is hyperpigmentation often seen in addison’s disease
Buccal mucosa
Skin creases
Pressure points
Recent scars
What causes postural hypotension in addison’s disease
Dehydration and low electrolytes (low aldosterone)
What can precipitate an addison’s crisis
Infection, illness
Symptoms of an addison’s crisis
Vomiting Abdominal pain Weakness Hypoglycaemia Hypovolaemic shock
What are some investigations that can be done for suspected addison’s disease
Cortisol measurement
ACTH level
ACTH stimulation test
What is the hptm, pituitary, thyroid axis
Hypothalamus makes TRH which stimulates anterior pituitary to make TSH which stimulates thyroid gland to make T4/T3
Difference between cushing’s disease and cushing’s syndrome
Cushing’s disease is specifically caused by ACTH over production by the pituitary gland causing excess glucocorticoid production.
Cushing’s syndrome can be caused by anything that causes excess glucocorticoids
Symptoms of cushings syndrome
Weight gain - central, trunk, abdomen
“Buffalo hump”
Moon face
Thin easily bruised skin
Purple striate on abdomen, breasts and thigh
Pigmentation in ACTH overproduction causes
Causes of cushings syndrome
ACTH dependent
Pituitary-dependent
Ectopic ACTH producing tumours
ACTH administration
ACTH independent
Adrenal gland malignancy
Glucocorticoid administration
What are some common ectopic ACTH producing tumours
Small cell lung cancer
Carcinoid tumours
what is the most common cause of lumps in the neck
reactive lymph node from infection (bacterial, viral or others)
how would a thyroglossal cyst be identified
midline lump
moves with swallowing and tongue protrusion
which age group is more likely to get inflammatory and congenital neck lumps
children and teens.
what is the onset pattern of
- inflammatory lump
- malignant lump
- salivary gland blockage
inflammatory lumps come and ago within 2-6 weeks.
malignant lumps enlarge progressively in a short time
transient swelling with associations with eating suggest salivary gland blockage
how to malignant lump necks tend to feel?
hard
what lumps move with swallowing?
thyroid gland swallowing and thyroglossal cysts
what does a tender lump indicate?
infection over the lump
what do midline lumps tend to be?
thyroid swelling
thyroglossal
dermoid cysts
what does a a bilateral tender swelling across the mandibular angle suggest
parotid infection (mumps)
where is virchows node and what does it suggest
left supraclavicular fossa
metastatic malignancy
signs and symptoms of bells palsy
unilateral facial muscle weakness facial tingling phonophobia some pain around ear loss of taste in anterior 2/3 of tongue on affected side
how to diagnose bells palsy?
by excluding other possible causes of unilateral facial weakness
4 side effects of med-long term steroid use
weight gain
skin thinning
hyperglycaemia -> Diabetes
brittle bones
what TSH, T4 and T3 pattern can suggest someone who is ‘sick euthyroid’
normal TSH
normal T4
low T3
(with ongoing illness)
what is a toxic adenoma (in hyperthyroidism)
solitary overactive nodule producing excess thyroid hormones
what is de Quervain’s thyroiditis
associated with viral infection or post-partum
patients experience period of hyperthyroid, then hypothyroidism before resolving back to euthyroidism.
what is carbimazole sometimes given for?
hyperthyroidism - Graves disease
what are the symptoms and signs of a ‘thyroid storm’ or thyroid crisis
hyperpyrexia
tachycardia
extreme restlessness
with more progression, it can lead to delirium, coma and death
what can precipitate a thyroid storm or thyroid crisis
infection
stress
surgery
radioactive iodine therapy
what causes addison’s disease?
autoimmune antibodies
why does vitiligo and loss of body hair happen in women with addison’s disease?
hair growth is dependent on adrenal androgens
what is the most common history of someone presenting in addison’s crisis?
someone who is on long term corticosteroid therapy, sudden withdrawal causing addison’s crisis
what does the short-ACTH test involve and show?
exogenous introduction of a small amount of ACTH, if cortisol does not go up, then it demonstrates primary adrenal insufficiency (problem is due to adrenal glands)
what further test can be done to determine secondary or tertiary hypoadrenalism?
CRH test.
symptoms of HHS
lethargy, confusion, focal neurological deficits, seizures,
leg weakness, cramps, visual impairment.
risk factors of HHS
type 2 diabetics, old, dementia, immunosuppressed
signs of HHS
signs of dehydration
tachycardia, hypotension, tachypnea
signs of cause of HHS - infection? thyroid? acute abdomen?
how to differentiate DKA from HHS?
level of ketones in bloods, “pear drops breath”, history (DKA is faster)
how to differentiate BPH from prostate cancer?
BPH is smooth on PR exam, prostate cancer is hard/irregular
how to diagnose prostate cancer?
transrectal ultrasound of prostate, elevated PSA, and biopsy
symptoms of prostate cancer
urgency, increased frequency, nocturia, dribbling, retention, or retention with overflow incontinence.
3 most common organisms causing UTI
E coli
proteus
staph saprotiphycius/epidermis
in an uncomplicated pyelonephritis, what is the likely cause of persistent illness despite 2-3 days of antibiotics? what should be done ti investigate?
do a imaging of utrinary tract to check for abscesses
what is the first investigation done for someone presenting with UTI symptoms?
urine dipstick - look for nitrites and luekocytes
definition of nephrotic syndrome?
proteinuria and hypoalbuminaemia
most common cause of nephrotic syndrome in children?
minimal change glomerular disease
symptoms of nephrotic syndrome?
facial swelling, wide spread edema
systemic fatigue, anorexia
which age group is more common in pharyngeal pouch?
> 70s
symptoms of pharyngeal pouch
chronic cough aspiration halitosis dysphagia regurgitation
what can an enlarged left supraclavicular lymph node suggest?
cancer of the internal organs
a new born baby is found to have several large lumpbs on the side of the neck, they are soft and appear fluid filled. what is an important thing to check in the newborn for fear of further complications?
ACBDE assessment and then chromsomal abnormalities
common age group for bells palsy
15-60
causes of bells palsy
can be after viral infection or idiopathic
how long does bells palsy usually last
about 3 weeks
investigations of a goitre?
blood tests - TFTs
imaging - US/Xray
Fine needle aspirate
a 10 year old with background of JIA, presents to the A&E with vomiting, abdominal pain, fatigue, muscle pains, cramps, and dehydration. what differentials have to be considered?
infection - gastroenteritis, sepsis
DKA
addison’s crisis
