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Urology Flashcards

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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
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

CCE AR version (20 decks)

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