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Flashcards in Urology Deck (218):
1

What are the indications for dialysis?

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

2

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?

Chronic bacterial prostatitis

3

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?

Bladder calculi
Painful haematuria suggests this rather than malignancy

4

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?

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

5

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

Haematuria
Loin pain
Abdo pain

6

What is nephrotic syndrome?

Too much protein excreted by kidney
Patient usually presents with oedema around the eyes and legs

7

What is the first line treatment for benign prostatic hyperplasia?

Tamulosin - alpha blocker

8

What is the second line treatment for benign prostatic hyperplasia?

Finasteride
Alpha reductase inhibitor which reduces dihydrotestosterone and therefore prostate volume

9

What should patients taking finasteride be warned about contraception?

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

10

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

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

11

What is the first line painkiller for renal colic pain?

Disclofenac rectally

12

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?

Seminoma - age and normal AFP

13

What is paraphimosis?

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

14

What is the management for paraphimosis?

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

15

What is balanitis?

Infection of glans usually caused by streptococcus or staph
Common in diabetics

16

On which side are varicocoeles most likely to occur?

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

17

Which veins are affected in a varicocoele?

Pampiniform plexus

18

What is the first line treatment for stress incontinence?

Pelvic floor exercises

19

What treatments are used in urge incontinence?

Bladder retraining
Oxybutynin - anticholinergic

20

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

Orchitis

21

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?

Spermatocoele

22

What are symptoms of hypercalcaemia?

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

23

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

Osmotic demyelination syndrome
(Central pontine demyelination)

24

What are the 5 Rs of IV fluid therapy?

Resuscitation
Routine maintenance
Replacement
Redistribution
Reassessment

25

Describe how total body water is divided up

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

26

What components of the extracellular compartment are there?

Intravascular: haematocrit and plasma
Interstitial

27

What contributes to plasma oncotic pressure?

Albumin
Haemoglobin
Globulin

28

Where can fluids be lost from?

Kidney
GIT
Skin
Lungs

29

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

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

30

What is insensible loss of fluid?

Evaporation of water from lungs and skin
0.5L - 1L/day

31

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

100-150ml

32

What factors can negatively affect fluid balance?

Changes in albumin
Changes in potassium
Malnutrition

33

Why can liver disease lead to oedema?

Reduced albumin levels
Reduces plasma oncotic pressure and intravascular volume

34

What is crystalloid fluid?

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

35

What are colloid fluids?

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

36

What is a balanced salt solution?

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

37

Which fluids are better for interstitial volume correction?

Crystalloids

38

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

Trans rectal ultrasonography

39

What is a Gleason score?

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

40

What is goserelin?

LH hormone releasing agonist
Suppress production of sex hormones

41

What characterises autosomal dominant Polycystic kidney disease?

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

42

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?

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

43

Which drugs could precipitate urinary retention?

Anticholinergic - TCAs
Antipsychotics - chlopromazine
Opiate analgesics

44

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

Diabetes
Hypertension
Glomerulopathies

45

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

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

46

What is the difference between bland and active urine sediments?

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

47

What are negative prognostic factors for glomerulopathies?

HTN
Greater degree renal impairment

48

What are pathological changes seen in diabetic nephropathy?

Glomerular basement membrane thickening
Mesangial expansion
Glomerulosclerosis

49

What is the commonest form of glomerulonephritits worldwide?

IgA nephropathy

50

What is the definition of chronic kidney disease?

GFR 65 mg/mmol
Protein/creatinine ratio 100mg/mmol

51

List some causes of chronic kidney disease

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

52

What are uraemic symptoms of CKD?

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

53

What are red cell and granular casts?

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

54

What are some complications of chronic kidney disease?

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

55

What is renoprotective management for chronic kidney disease?

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

56

What are treatment aims for chronic kidney disease renoprotection?

BP

57

What can be complications of haemodialysis?

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

58

What can be complications of continuous ambulatory peritoneal dialysis?

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

59

What are contraindications to continuous ambulatory peritoneal dialysis?

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

60

What are complications of renal transplant?

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

61

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

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

62

What are the boundaries of hesselbachs triangle?

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

63

In which type of inguinal hernia is strangulation most common?

Indirect - narrow neck

64

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

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

65

What are the different sub classifications of inguinal hernias?

Reducible
Irreducible or incarcerated
Strangulated

66

What are possible complications of an inguinal hernia repair?

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

67

In which babies are hydrocoeles more common?

Premature
Testes descend late

68

What are some possible complications of a hydrocoele?

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

69

What factors make up nephrotic syndrome?

Proteinuria
Hypoalbuminaemia
Oedema

70

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

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

71

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

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

72

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

Hyponatraemia in elderly and children with SIADH

73

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

0.9% sodium chloride
Ringers lactate
Hartmanns solution

74

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

0.18% sodium chloride/4% dextrose
5% dextrose (initially isotonic)

75

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

3% sodium chloride

76

Which fluid is most useful to give in hypoglycaemia?

5% dextrose
25% or 50% glucose

77

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

Hartmanns
Ringers lactate
0.9% sodium chloride

78

Which fluid is most useful in a hyponatraemic patient?

0.9% sodium chloride

79

What are some indications for IV fluids?

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

80

What is the constitution of Hartmanns solution?

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

81

What are risks of giving IV fluids?

Hyponatraemia
Sodium/chloride and water overload
Pulmonary oedema

82

How can you monitor patients receiving IV fluid?

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

83

Give examples of when fluid resuscitation is useful

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

84

What is the recommendation for IV fluid for resuscitation purposes?

500ml of balanced crystalloid stat (less than 15 mins)
250ml if cardiac failure

85

What are the principles of fluid replacement?

Daily maintenance requirements
Plus like for like water and electrolyte replacement for any losses

86

What are the aims of fluid maintenance?

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

87

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

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

88

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

50-100g per day

89

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

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

90

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

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

91

Why can resuscitation with crystalloid solution lead to pulmonary oedema?

Dilutes plasma proteins so reduces plasma oncotic pressure

92

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

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

93

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

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

94

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?

Hydrocoele

95

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?

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

96

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?

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

97

Why can a ruptured AAA mimic Ureteric colic?

Pooling of blood from the aorta into the retroperitoneum

98

What are risk factors for testicular torsion?

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

99

How do you calculate corrected calcium?

Serum calcium + 0.8 X (4- serum albumin)

100

What is prehns sign?

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

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

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

What are risk factors for testicular cancer?

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

What investigations might you order in a suspected testicular tumour?

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

104

During what week of development does the processus vaginalis form?

12th

105

How long is the inguinal canal in adults?

4-6 cm

106

What are the boundaries of the inguinal canal?

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

What are the boundaries of hesselbachs triangle?

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

108

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

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

109

What is the contents of the spermatic cord?

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

What is the femoral sheath?

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

111

What are the borders of the femoral canal?

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

112

What is cloquets node?

Lymph node in inguinal region
Part of deep inguinal node group

113

Describe pathway of sperm from seminiferous tubule to ductus deferens

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

114

What is the epididymis?

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

115

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

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

Describe venous drainage of the testes

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

Where does lymph drain to from the testes?

Pre aortic nodes

118

Give some ddx for inguinal swelling

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

119

Give some ddx for scrotal swelling

Testicular tumour
Hydrocoele
Epididymal cyst
Spermatocoele
Varicocoele
Inguinoscrotal hernia

120

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

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

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

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

What investigations can be performed for a scrotal lump?

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

123

What can be causes of inguinal lymphadenopathy?

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

124

What would do to manage a patient with inguinal lymphadenopathy?

Exclude inflamatory cause: Abx/observe
Exclude malignancy: Biopsy, FNAC/Open

125

What are some causes of a saphenous varix?

Idiopathic
Pregnancy
Pelvic mass
Dvt

126

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

Disappears on lying flat

127

What should be done to diagnose a saphenous varix?

Doppler/duplex

128

What is the treatment for a saphenous varix?

Endovascular surgery

129

What are differences between true and false femoral artery aneurysms?

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

130

What is used to diagnose a femoral artery aneurysm?

Duplex scan

131

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

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

132

What is cryptorchidism?

Absence of one or both testes from the scrotum

133

What are problems with cryptorchidism?

Subfertility/sterlity
Torsion
Trauma
Malignancy

134

By what age should both testes be descended?

2 years

135

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

CT chest abdo pelvis
Tumour markers

136

What are the different classifications of hydrocoele?

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

What can causes of a hydrocoele?

Congenital: communicating
Reactive: tumour, infection, trauma
Idiopathic

138

What investigations and management should be done for a hydrocoele?

USS/exclude malignancy
Aspiration not helpful
Surgery

139

What is a varicocoele?

Dilation of pampiniform plexuses of veins

140

On which side is a varicocoele most likely to occur?

Left

141

What is a potential long term consequence of a varicocoele?

Infertility

142

How does a varicocoele usually present?

Painless lump
Bag of worms
May reduce on lying down

143

What investigations and management should be done for a varicocoele?

USS: Exclude sinister cause
Ligation at deep ring

144

What can cause epididymo orchitis?

Gonorrhea
Chlamydia
E coli (most common)
Mycobacterium tuberculosis
Amiodarone

145

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

6 hours
After 12 hours, the testis cannot be salvaged

146

What is the treatment for testicular torsion?

Orchidopexy bilaterally

147

What is a hernia?

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

148

What are the different clinical classifications of hernias?

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

What does inguinal hernia repair aim to achieve?

Strengthen posterior inguinal wall with mesh

150

Where anatomically are you likely to find a femoral hernia?

Neck of the sac is below and lateral the pubic tubercle

151

What is a femoral hernia most likely to contain?

Omentum

152

Name 3 complications of mesh hernia repair

Recurrence
Mesh infection
Haematoma formation
Seroma formation

153

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?

Ilioinguinal nerve

154

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

Seminoma

155

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?

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

What structures are at risk during a femoral hernia repair ?

Femoral vein
Accessory obturator artery

157

What are management steps for testicular torsion?

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

158

What measurements are required for diagnosis of CKD?

EGFR x2 and albumin creatinine ratio

159

What is the management for CKD?

Identify/treat cause
Medication
Control BP
ACE if proteinuria

160

What is Peyronie's disease?

Fibrosis in plantar fascia and penis

161

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

Pooling of blood from aorta into retroperitoneum

162

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

Metformin
Lithium
Digoxin

163

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

NSAIDs
Aminoglycosides
ACE inhibitors
ARBs
Diuretics

164

What are treatments for hyperkalaemia?

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

165

What are normal maintenance requirements for fluids and electrolytes?

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

166

What are signs and symptoms of salt and water retention?

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

167

What are signs and symptoms of salt and water depletion?

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

168

What are causes of hyperkalaemia?

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

What are the clinical manifestations of hyperkalaemia?

Cardiac arrhythmia and arrest
Ascending muscle weakness

170

How do you manage hyperkalaemia?

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

171

What are causes for hypokalaemia?

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

What are clinical manifestations of hypokalaemia?

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

173

What ECG changes are present in hypokalaemia?

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

What is the treatment for hypokalaemia?

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

175

What are causes of hyponatraemia?

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

What is acute hyponatraemia?

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

177

What are symptoms of hyponatraemia?

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

178

How do you manage severe symptoms of hyponatraemia?

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

What is central pontine myelinolysis?

Rapid correction of hyponatraemia
Leads to coma and paralysis

180

What are causes of hypernatraemia?

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

181

What investigations should be done for hypernatraemia?

Glucose
Serum osmolality
Urine osmolality
If DI suspected: desmopressin test

182

What is the treatment for diabetes insipidus?

Treat cause
Replace fluid - 0.45% saline 5% dextrose

183

What is a normal anion gap?

8-16

184

How do you calculate anion gap?

Sodium - (chloride and bicarbonate)

185

What are some causes of a raised anion gap?

Methanol
Uraemia
DKA
Isoniazid
Lactic acidosis
Ethanol
Renal failure
Salicylates

186

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

Renal tubular acidosis
Addison's
Acetazolamide
Diarrhoea

187

What is management for severe metabolic acidosis?

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

188

What are some respiratory causes for respiratory acidosis?

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

189

What are some causes of metabolic alkalosis?

Vomiting
Conns
Cushing's
Excess alkali ingestion

190

What is the AKIN criteria for AKI?

Stage 1: creatinine raised 1.5-2x, urine

191

What are potential complications of AKI?

Hyperkalaemia
Pulmonary oedema
Acidosis
Uraemia

192

What are the principles of managing AKI?

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

193

What are some systemic causes of haematuria?

Coagulation disorders
Sickle trait
Vasculitis
Sub-acute bacterial endocarditis

194

What are some renal causes of haematuria?

Infection
Glomerular disease
Malignancy
Infarction
Trauma
Cystic disease
Vascular malformations

195

What are some Ureteric causes of haematuria?

Calculi
Malignancy

196

What are some bladder causes of haematuria?

Infection
Malignancy
Calculi

197

What are some outflow tract causes for haematuria?

Prostate malignancy
Trauma
Prostatitis

198

What investigations might you do for haematuria?

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

What cell type does a renal cell carcinoma originate from?

Proximal renal tubular epithelium

200

What factors increase the risk of renal cell carcinoma?

PCKD
Middle aged man
Tuberous sclerosis
Smoking
Von Hippel Lindau syndrome

201

What are symptoms of a renal cell carcinoma?

Haematuria
Loin pain
Abdominal mass

202

What are risk factors for bladder cancer?

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

What are symptoms of bladder cancer?

Dysuria
Presence of risk factors
Painless haematuria

204

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

At least 2

205

What can cause acute urinary retention in a man?

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

What can cause acute urinary retention in a woman?

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

What drugs can cause acute urinary retention?

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

208

What drugs can lead to chronic urinary retention?

Antispasmodics
Antihistamines
Anticholinergics
Botulinum toxin

209

What factors increase the risk of prostate cancer?

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

210

What can be symptoms of prostate cancer?

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

211

What investigations can be done for prostate cancer?

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

212

What are treatment options for prostate cancer?

Watchful waiting
Radical prostatectomy
Radiotherapy
Hormonal therapy

213

What is IgA nephropathy?

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

214

How might IgA nephropathy present?

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

215

What is trousseau's sign?

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

216

What is chvosteks sign?

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

217

What is L'Hermitte's sign?

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

218

What is kernigs sign?

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