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  • Question 1 - You are assisting in the care of a 65-year-old man who has been...

    Incorrect

    • You are assisting in the care of a 65-year-old man who has been hospitalized for chest pain. He has a medical history of hypertension, angina, and is a current smoker of 20 cigarettes per day. Upon admission, blood tests were conducted in the Emergency Department and revealed the following results:
      - Na+ 133 mmol/l
      - K+ 3.3 mmol/l
      - Urea 4.5 mmol/l
      - Creatinine 90 µmol/l
      What is the most likely cause of the electrolyte abnormalities observed in this patient?

      Your Answer: His smoking history

      Correct Answer: Bendroflumethiazide therapy

      Explanation:

      Hyponatraemia and hypokalaemia are caused by bendroflumethiazide, while spironolactone is linked to hyperkalaemia. Smoking would only be significant if the patient had lung cancer that resulted in syndrome of inappropriate ADH secretion, but there is no evidence of this in the given scenario.

      Thiazide diuretics are medications that work by blocking the thiazide-sensitive Na+-Cl− symporter, which inhibits sodium reabsorption at the beginning of the distal convoluted tubule (DCT). This results in the loss of potassium as more sodium reaches the collecting ducts. While loop diuretics are better for reducing overload, thiazide diuretics have a role in the treatment of mild heart failure. Bendroflumethiazide was commonly used for managing hypertension, but recent NICE guidelines recommend other thiazide-like diuretics such as indapamide and chlortalidone.

      Like any medication, thiazide diuretics have potential adverse effects. Common side effects include dehydration, postural hypotension, and electrolyte imbalances such as hyponatraemia, hypokalaemia, and hypercalcaemia. Gout, impaired glucose tolerance, and impotence are also possible. Rare adverse effects include thrombocytopaenia, agranulocytosis, photosensitivity rash, and pancreatitis.

      To manage hypertension, current NICE guidelines recommend using thiazide-like diuretics such as indapamide or chlortalidone as first-line treatment. If blood pressure is not adequately controlled, a calcium channel blocker or ACE inhibitor can be added. If blood pressure remains high, a thiazide-like diuretic can be combined with a calcium channel blocker or ACE inhibitor. In some cases, a beta-blocker or aldosterone antagonist may also be added. Regular monitoring and adjustment of medication is necessary to ensure optimal blood pressure control.

    • This question is part of the following fields:

      • Renal Medicine/Urology
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  • Question 2 - A 25-year-old man presents to your GP clinic with concerns of a possible...

    Correct

    • A 25-year-old man presents to your GP clinic with concerns of a possible urinary tract infection. He reports experiencing burning sensations during urination for the past two weeks, particularly in the morning. Additionally, he has noticed some itching around his penis. The patient has no significant medical history. During the examination, you observe that his abdomen is soft and nontender. Upon performing a urine dip, you find that it is positive for leukocytes. What is the most probable cause of his symptoms?

      Your Answer: Urethritis due to a sexually transmitted infection

      Explanation:

      The BASH guidelines for Sexually Transmitted Infections in Primary Care state that in young men, urethritis is typically caused by an STI. Men under the age of 35 rarely experience urine infections, so any sexually active man experiencing dysuria should be screened for STIs. The presence of leukocytes in the urine indicates the presence of pus cells, which are a result of an STI. Chlamydia is the most prevalent STI in the UK.

      Chlamydia is a common sexually transmitted infection caused by Chlamydia trachomatis. It is prevalent in the UK, with approximately 1 in 10 young women affected. The incubation period is around 7-21 days, but many cases are asymptomatic. Symptoms in women include cervicitis, discharge, and bleeding, while men may experience urethral discharge and dysuria. Complications can include epididymitis, pelvic inflammatory disease, and infertility.

      Traditional cell culture is no longer widely used for diagnosis, with nuclear acid amplification tests (NAATs) being the preferred method. Testing can be done using urine, vulvovaginal swab, or cervical swab. Screening is recommended for sexually active individuals aged 15-24 years, and opportunistic testing is common.

      Doxycycline is the first-line treatment for Chlamydia, with azithromycin as an alternative if doxycycline is contraindicated or not tolerated. Pregnant women may be treated with azithromycin, erythromycin, or amoxicillin. Patients diagnosed with Chlamydia should be offered partner notification services, with all contacts since the onset of symptoms or within the last six months being notified and offered treatment.

    • This question is part of the following fields:

      • Renal Medicine/Urology
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  • Question 3 - A 55-year-old woman presents to the Emergency Department with blood-stained urine and coughing...

    Incorrect

    • A 55-year-old woman presents to the Emergency Department with blood-stained urine and coughing up blood.

      On examination, her temperature is 38.2 °C. Her blood pressure is 160/100 mmHg, while her pulse is 92 beats per minute. Her respiratory rate is 20 breaths per minute. Urine testing is positive for protein and red cell casts. Antibodies to the glomerular basement membrane are found on serum testing. A renal biopsy is performed.

      What is likely to be seen on the renal biopsy?

      Your Answer: A ‘lumpy bumpy’ appearance of the glomeruli

      Correct Answer: Linear immunofluorescence

      Explanation:

      Differentiating Glomerular Diseases: Characteristics and Immunofluorescence Findings

      Nephritic syndrome is a condition characterized by proteinuria, haematuria, and hypertension. The presence of anti-glomerular basement membrane antibodies suggests hypersensitivity angiitis or Goodpasture’s syndrome as the underlying cause. In this disease, crescent-shaped glomeruli are observed in renal biopsy specimens. Linear immunofluorescence reveals the deposition of immunoglobulin G (IgG) along the basement membrane.

      Other glomerular diseases have distinct characteristics and immunofluorescence findings. Acute post-streptococcal glomerulonephritis, commonly seen in children, presents with a lumpy bumpy appearance of the glomeruli. Immunoglobulin A (IgA) nephropathy is characterized by immune complex deposition in the basement membrane. Hereditary nephritis or Alport syndrome, which is associated with deafness, shows splitting of the basement membrane. Finally, diffuse membranous glomerulonephritis presents with wire looping of capillaries.

      In summary, recognizing the distinct characteristics and immunofluorescence findings of glomerular diseases is crucial in making an accurate diagnosis and providing appropriate treatment.

    • This question is part of the following fields:

      • Renal Medicine/Urology
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  • Question 4 - A 67-year-old man complains of lower urinary tract symptoms. He has been experiencing...

    Correct

    • A 67-year-old man complains of lower urinary tract symptoms. He has been experiencing urinary urgency and occasional incontinence for the past few months. He reports no difficulty with urinary flow, hesitancy, or straining. Prostate examination and urinalysis reveal no abnormalities. What medication is most likely to relieve his symptoms?

      Your Answer: Antimuscarinic

      Explanation:

      Patients with an overactive bladder can benefit from antimuscarinic drugs. Oxybutynin, tolterodine, and darifenacin are some examples of effective medications. However, before resorting to medication, it is important to discuss conservative measures with the patient and offer bladder training.

      Lower urinary tract symptoms (LUTS) are a common issue in men over the age of 50, with benign prostatic hyperplasia being the most common cause. However, other causes such as prostate cancer should also be considered. These symptoms can be classified into three groups: voiding, storage, and post-micturition. To properly manage LUTS, it is important to conduct a urinalysis to check for infection and haematuria, perform a digital rectal examination to assess the size and consistency of the prostate, and possibly conduct a PSA test after proper counselling. Patients should also complete a urinary frequency-volume chart and an International Prostate Symptom Score to guide management.

      For predominantly voiding symptoms, conservative measures such as pelvic floor muscle training, bladder training, and prudent fluid intake can be helpful. If symptoms are moderate or severe, an alpha-blocker may be offered. If the prostate is enlarged and the patient is at high risk of progression, a 5-alpha reductase inhibitor should be offered. If there are mixed symptoms of voiding and storage not responding to an alpha-blocker, an antimuscarinic drug may be added. For predominantly overactive bladder symptoms, moderating fluid intake and bladder retraining should be offered, and antimuscarinic drugs may be prescribed if symptoms persist. Mirabegron may be considered if first-line drugs fail. For nocturia, moderating fluid intake at night, furosemide 40mg in the late afternoon, and desmopressin may be helpful.

    • This question is part of the following fields:

      • Renal Medicine/Urology
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  • Question 5 - A 65-year-old patient with hypertension is brought to his general practitioner by his...

    Incorrect

    • A 65-year-old patient with hypertension is brought to his general practitioner by his daughter because of haematuria. While taking the history, it becomes apparent that he has had blood in his urine for the past two months and it has gotten progressively worse. Now he also has left flank pain. He has lost 8 lb in the past month without trying. He denies dysuria, fever, nausea and chills. His family history is significant only for ‘diabetes’ in both parents. He has a 40-pack-year history, drinks an occasional glass of wine and denies any history of illicit drug use.
      On examination, he is afebrile and his vital signs are stable. On deep palpation of his left upper quadrant, there is a firm, non-mobile mass.
      What is the most likely diagnosis?

      Your Answer: Prostate cancer with retroperitoneal metastases

      Correct Answer: Renal cell carcinoma

      Explanation:

      Differential Diagnosis for a Patient with Haematuria, Flank Pain, and Palpable Mass

      The patient in question presents with haematuria, flank pain, and a palpable mass, which are indicative of renal cell carcinoma. This triad of symptoms is only seen in a small percentage of patients and is often referred to as the too late triad because it indicates a poor prognosis. Renal cell carcinoma arises from the epithelial lining of the proximal convoluted tubule and has a tendency to metastasize haematogenously.

      Other potential diagnoses include chronic pyelonephritis with abscess formation, which is typically seen in patients with anatomical defects in the genitourinary tract. A partially obstructive renal calculus can also cause haematuria, but it is not associated with a palpable mass, and the history of insidious onset and unintentional weight loss are suggestive of malignancy.

      Prostate cancer with retroperitoneal metastases is another potential diagnosis, but it does not typically cause haematuria. Transitional cell carcinoma of the bladder is a possibility, given the patient’s smoking history and haematuria, but the flank pain and abdominal mass make renal cell carcinoma the most likely diagnosis.

    • This question is part of the following fields:

      • Renal Medicine/Urology
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  • Question 6 - A 65-year-old man with chronic kidney failure has been instructed by his nephrologist...

    Incorrect

    • A 65-year-old man with chronic kidney failure has been instructed by his nephrologist to adhere to a 'renal diet'. He visits you to gain further knowledge about this. What is typically recommended to individuals with chronic kidney disease?

      Your Answer: High calcium diet

      Correct Answer: Low potassium diet

      Explanation:

      Dietary Recommendations for Chronic Kidney Disease Patients

      Chronic kidney disease patients are recommended to follow a specific diet to reduce the strain on their kidneys. This diet includes low levels of protein, phosphate, sodium, and potassium. The reason for this is that these substances are typically excreted by the kidneys, and reducing their intake can help ease the burden on the kidneys. By following this diet, patients can help slow the progression of their kidney disease and improve their overall health. It is important for patients to work with a healthcare professional or registered dietitian to ensure they are meeting their nutritional needs while following these dietary restrictions.

    • This question is part of the following fields:

      • Renal Medicine/Urology
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  • Question 7 - As a foundation doctor in general practice, you encounter a patient who is...

    Incorrect

    • As a foundation doctor in general practice, you encounter a patient who is fifty-five years old and has a past medical history of prostatitis. He is interested in getting a prostate specific antigen test done due to his family's history of prostate cancer. What would be an appropriate time to conduct the test?

      Your Answer: One week after his prostatitis diagnosis

      Correct Answer: One month after his prostatitis diagnosis

      Explanation:

      To prevent false results, it is recommended to refrain from conducting a prostate specific antigen test within a month of prostatitis. This is because prostatitis can cause an increase in PSA levels. It is important to note that a digital rectal examination cannot replace a PSA test. Additionally, if a patient is not experiencing any symptoms, conducting the test may lead to unnecessary investigations. It is also important to keep in mind that a normal PSA level does not necessarily rule out the possibility of prostate cancer.

      Prostate specific antigen (PSA) is an enzyme produced by both normal and cancerous prostate cells. It is commonly used as a marker for prostate cancer, but its effectiveness as a screening tool is still debated. The NHS Prostate Cancer Risk Management Programme (PCRMP) has released guidelines for handling requests for PSA testing in asymptomatic men. While a recent European trial showed a reduction in prostate cancer deaths, it also revealed a high risk of over-diagnosis and over-treatment. As a result, the National Screening Committee has decided not to introduce a screening programme, but rather allow men to make an informed decision. The PCRMP recommends age-adjusted upper limits for PSA levels, while NICE Clinical Knowledge Summaries suggest a lower threshold for referral. PSA levels can also be raised by factors such as benign prostatic hyperplasia, prostatitis, and urinary tract infections.

      The specificity and sensitivity of PSA testing are poor, with a significant number of men with elevated PSA levels not having prostate cancer, and some with normal PSA levels having the disease. Various methods are used to add meaning to PSA levels, including age-adjusted upper limits and monitoring changes in PSA levels over time. It is also debated whether digital rectal examination causes a rise in PSA levels. It is important to note that PSA testing should be postponed after certain events, such as ejaculation or instrumentation of the urinary tract.

    • This question is part of the following fields:

      • Renal Medicine/Urology
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  • Question 8 - A 28-year-old G1P0 woman attends her routine antenatal appointment at 12 weeks gestation...

    Incorrect

    • A 28-year-old G1P0 woman attends her routine antenatal appointment at 12 weeks gestation and reports experiencing burning retrosternal pain. Omeprazole is prescribed, and a urine sample is taken. The urinalysis shows trace protein with no haematuria, nitrates, or white cells, and the patient denies any urinary symptoms. During the appointment, her blood pressure is measured at 135/88 mmHg. Upon further testing, the urine sample is found to have scant growth of Escherichia coli. What is the most appropriate course of action?

      Your Answer: Prescribe aspirin, labetalol, and a 7-day course of nitrofurantoin

      Correct Answer: Prescribe a 7 day course of nitrofurantoin

      Explanation:

      Asymptomatic bacteriuria in pregnant women should be treated promptly with antibiotics. The recommended treatment is a 7-day course of nitrofurantoin. This is important to prevent the development of symptomatic urinary tract infection or pyelonephritis. Nitrofurantoin is safe to use in the first and second trimester, but should be avoided in the third trimester due to the risk of neonatal haemolysis. The patient’s blood pressure is within normal range and does not require treatment. The trace of protein in her urine is likely related to her asymptomatic bacteriuria and should be monitored with subsequent urine dips. Antihypertensive treatment is not necessary based on the trace of protein alone. Prescribing a 7-day course of trimethoprim is not recommended as it is contraindicated in the first trimester of pregnancy due to the increased risk of neural-tube defects. Prescribing aspirin, labetalol, and a 7-day course of nitrofurantoin is not necessary as the patient does not meet the diagnostic criteria for pre-eclampsia or pregnancy-induced hypertension. Similarly, prescribing aspirin, labetalol, and a 7-day course of trimethoprim is not recommended for the same reasons.

      Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. The management of UTIs depends on various factors such as the patient’s age, gender, and pregnancy status. For non-pregnant women, local antibiotic guidelines should be followed if available. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. However, if the patient is aged over 65 years or has visible or non-visible haematuria, a urine culture should be sent. Pregnant women with UTIs should be treated with nitrofurantoin, amoxicillin, or cefalexin for seven days. Trimethoprim should be avoided during pregnancy as it is teratogenic in the first trimester. Asymptomatic bacteriuria in pregnant women should also be treated to prevent progression to acute pyelonephritis. Men with UTIs should be offered a seven-day course of trimethoprim or nitrofurantoin unless prostatitis is suspected. A urine culture should be sent before antibiotics are started. Catheterised patients should not be treated for asymptomatic bacteria, but if symptomatic, a seven-day course of antibiotics should be given. Acute pyelonephritis requires hospital admission and treatment with a broad-spectrum cephalosporin or quinolone for 10-14 days. Referral to urology is not routinely required for men who have had one uncomplicated lower UTI.

    • This question is part of the following fields:

      • Renal Medicine/Urology
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  • Question 9 - A 64-year-old man with chronic kidney disease due to diabetes mellitus is being...

    Incorrect

    • A 64-year-old man with chronic kidney disease due to diabetes mellitus is being evaluated. In evaluating his estimated glomerular filtration rate (eGFR), which of the following variables is not necessary for the Modification of Diet in Renal Disease (MDRD) equation?

      Your Answer: Gender

      Correct Answer: Serum urea

      Explanation:

      The eGFR (estimated glomerular filtration rate) is determined by several variables, including CAGE, which stands for Creatinine, Age, Gender, and Ethnicity.

      Understanding Chronic Kidney Disease: eGFR and Classification

      Chronic kidney disease (CKD) is a condition that affects the kidneys’ ability to filter waste products from the blood. Serum creatinine, a commonly used measure of kidney function, may not provide an accurate estimate due to differences in muscle mass. To address this, formulas such as the Modification of Diet in Renal Disease (MDRD) equation were developed to estimate the glomerular filtration rate (eGFR). The MDRD equation takes into account variables such as serum creatinine, age, gender, and ethnicity.

      It is important to note that certain factors may affect the accuracy of eGFR results, such as pregnancy, muscle mass, and recent consumption of red meat. CKD can be classified based on eGFR, with stage 1 indicating a GFR greater than 90 ml/min with some sign of kidney damage on other tests. Stage 2 indicates a GFR of 60-90 ml/min with some sign of kidney damage, while stage 3a and 3b indicate a moderate reduction in kidney function with GFR ranges of 45-59 ml/min and 30-44 ml/min, respectively. Stage 4 indicates a severe reduction in kidney function with a GFR range of 15-29 ml/min, while stage 5 indicates established kidney failure with a GFR less than 15 ml/min, which may require dialysis or a kidney transplant. It is important to note that if all kidney tests are normal, there is no CKD.

    • This question is part of the following fields:

      • Renal Medicine/Urology
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  • Question 10 - A 63-year-old woman who is undergoing treatment for bladder cancer presents to the...

    Incorrect

    • A 63-year-old woman who is undergoing treatment for bladder cancer presents to the Emergency Department because she has noticed that the urine in her catheter is blood-stained.
      On examination, the urine is pink in colour. Her observations are normal.
      What would be the next most appropriate step in this patient’s management?
      Select the SINGLE most likely option.

      Your Answer: Flush the urinary catheter using normal saline

      Correct Answer: Arrange a full blood count

      Explanation:

      Management of a Patient with Suspected Bladder Tumour and Bleeding

      When managing a patient with suspected bladder tumour and bleeding, it is important to consider the appropriate steps to take. Here are some options and their potential outcomes:

      1. Arrange a full blood count: This test can help assess the degree of blood loss and guide the urgency of treatment.

      2. Transfuse two units of O-negative blood: While patients with bladder tumours can bleed extensively, it is important to first assess the need for transfusion through a full blood count.

      3. Flush the urinary catheter using normal saline: This step is appropriate for a blocked catheter, but not for a patient with active bleeding.

      4. Remove the urinary catheter: This step can cause blood clots and urinary retention, and is not indicated for this patient.

      5. Transfer to theatre for resection of tumour: While this may be necessary in cases of catastrophic bleeding, it is important to first assess the patient’s stability and obtain blood tests before planning definitive management.

      In summary, careful consideration of the appropriate steps is crucial in managing a patient with suspected bladder tumour and bleeding.

    • This question is part of the following fields:

      • Renal Medicine/Urology
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  • Question 11 - A 10-year-old child with a history of infective diarrhoea presents with fever, hypertension,...

    Incorrect

    • A 10-year-old child with a history of infective diarrhoea presents with fever, hypertension, haematuria and bloody stools two weeks later. What could be a potential diagnosis?

      Your Answer: Acute interstitial nephritis

      Correct Answer: Haemolytic uraemic syndrome

      Explanation:

      Haemolytic uraemic syndrome (HUS) is a condition that causes progressive kidney failure and is associated with microangiopathic haemolytic anaemia and thrombocytopenia. There are two main types of HUS, one of which is associated with Shiga-like toxin (Stx) and is commonly seen in children who have had diarrhoea. The classic form of Stx-HUS is often caused by E. coli O157:H7 and is characterized by a history of gastroenteritis, fever, bloody diarrhoea, oedema, and hypertension. Henoch-Schönlein purpura is an acute disorder that affects small blood vessels in various parts of the body, including the skin, gastrointestinal tract, kidneys, and joints. It is characterized by a rash with bullae and ulcers, which typically appears in crops. Post-infectious glomerulonephritis is a condition that occurs after a streptococcal infection and is characterized by haematuria, proteinuria, red blood cell casts in the urine, oedema, and hypertension. Membranoproliferative glomerulonephritis is a rare cause of chronic nephritis that occurs primarily in children and young adults and may be idiopathic or secondary in aetiology. Acute interstitial nephritis is a condition that causes sudden kidney dysfunction, fever, and occasionally a rash, and is often associated with drug use.

    • This question is part of the following fields:

      • Renal Medicine/Urology
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  • Question 12 - A 58-year-old woman complains of developing urinary incontinence. She reports no urinary urgency...

    Correct

    • A 58-year-old woman complains of developing urinary incontinence. She reports no urinary urgency or pain, but experiences leakage of urine when she coughs or laughs. What is the best initial approach to manage this condition?

      Your Answer: Pelvic floor muscle training

      Explanation:

      The initial treatment for urinary incontinence differs depending on the type. For urge incontinence, bladder retraining is the recommended first-line approach. On the other hand, for stress incontinence, pelvic floor muscle training is the preferred initial treatment.

      Understanding Urinary Incontinence: Causes, Classification, and Management

      Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

      Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

      In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

    • This question is part of the following fields:

      • Renal Medicine/Urology
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  • Question 13 - A 35-year-old woman who is 36 weeks pregnant complains of dysuria and frequent...

    Correct

    • A 35-year-old woman who is 36 weeks pregnant complains of dysuria and frequent urination. Upon urine dipstick examination, nitrites and leukocytes are detected. What is the most appropriate course of action?

      Your Answer: Cefalexin

      Explanation:

      In this scenario, it is also advisable to use Amoxicillin.

      Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. The management of UTIs depends on various factors such as the patient’s age, gender, and pregnancy status. For non-pregnant women, local antibiotic guidelines should be followed if available. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. However, if the patient is aged over 65 years or has visible or non-visible haematuria, a urine culture should be sent. Pregnant women with UTIs should be treated with nitrofurantoin, amoxicillin, or cefalexin for seven days. Trimethoprim should be avoided during pregnancy as it is teratogenic in the first trimester. Asymptomatic bacteriuria in pregnant women should also be treated to prevent progression to acute pyelonephritis. Men with UTIs should be offered a seven-day course of trimethoprim or nitrofurantoin unless prostatitis is suspected. A urine culture should be sent before antibiotics are started. Catheterised patients should not be treated for asymptomatic bacteria, but if symptomatic, a seven-day course of antibiotics should be given. Acute pyelonephritis requires hospital admission and treatment with a broad-spectrum cephalosporin or quinolone for 10-14 days. Referral to urology is not routinely required for men who have had one uncomplicated lower UTI.

    • This question is part of the following fields:

      • Renal Medicine/Urology
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  • Question 14 - A 50-year-old woman comes to the emergency department complaining of dysuria. She denies...

    Correct

    • A 50-year-old woman comes to the emergency department complaining of dysuria. She denies any cough, shortness of breath, nausea or vomiting, or changes in bowel habits. She has a medical history of breast cancer and is currently undergoing treatment with doxorubicin and cyclophosphamide.

      Upon examination, her temperature is 38.1ºC, her heart rate is 93 bpm, her blood pressure is 120/75 mmHg, and her oxygen saturations are 97% on room air. Cardiovascular and abdominal examinations reveal no abnormalities. There are no visible skin changes and she does not appear to be visibly ill.

      What is the most appropriate next step in her management?

      Your Answer: Immediately prescribe IV piperacillin/tazobactam

      Explanation:

      In cases where neutropenic sepsis is suspected, immediate administration of IV antibiotics, such as piperacillin/tazobactam, is crucial, even if the diagnosis has not been confirmed yet. This is because patients with neutropenic sepsis may not exhibit obvious signs or symptoms of infection due to their weakened immune response, and delaying treatment can be potentially fatal. Therefore, waiting for the results of a full blood count or blood cultures is not recommended before starting treatment. While blood cultures should be taken as soon as possible, broad-spectrum antibiotics should be given first to provide urgent cover. Nitrofurantoin may be used for a urinary tract infection, but it is not appropriate for immediate treatment of neutropenic sepsis.

      Neutropenic Sepsis: A Common Complication of Cancer Therapy

      Neutropenic sepsis is a frequent complication of cancer therapy, particularly chemotherapy. It typically occurs within 7-14 days after chemotherapy and is characterized by a neutrophil count of less than 0.5 * 109 in patients undergoing anticancer treatment who exhibit a temperature higher than 38ºC or other signs or symptoms consistent with clinically significant sepsis.

      To prevent neutropenic sepsis, patients who are likely to have a neutrophil count of less than 0.5 * 109 as a result of their treatment should be offered a fluoroquinolone. In the event of neutropenic sepsis, antibiotics must be initiated immediately, without waiting for the white blood cell count.

      According to NICE guidelines, empirical antibiotic therapy should begin with piperacillin with tazobactam (Tazocin) immediately. While some units may add vancomycin if the patient has central venous access, NICE does not support this approach. After initial treatment, patients are typically assessed by a specialist and risk-stratified to determine if they may be able to receive outpatient treatment.

      If patients remain febrile and unwell after 48 hours, an alternative antibiotic such as meropenem may be prescribed, with or without vancomycin. If patients do not respond after 4-6 days, the Christie guidelines suggest ordering investigations for fungal infections (e.g. HRCT) rather than blindly initiating antifungal therapy. In selected patients, G-CSF may be beneficial.

    • This question is part of the following fields:

      • Renal Medicine/Urology
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  • Question 15 - You are examining test results. The midstream urine specimen (MSU) of a 26-year-old...

    Incorrect

    • You are examining test results. The midstream urine specimen (MSU) of a 26-year-old woman who is 14 weeks pregnant indicates a urinary tract infection. During the discussion of the outcome with the patient, she reports experiencing dysuria and having 'foul-smelling urine.' What is the best course of action?

      Your Answer: Ciprofloxacin for 7 days

      Correct Answer: Nitrofurantoin for 7 days

      Explanation:

      As the woman is experiencing symptoms, she requires treatment with a pregnancy-safe antibiotic. Trimethoprim is not recommended for use during the first trimester of pregnancy, making nitrofurantoin the appropriate choice. According to NICE CKS, amoxicillin should not be used due to its high resistance levels.

      Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. The management of UTIs depends on various factors such as the patient’s age, gender, and pregnancy status. For non-pregnant women, local antibiotic guidelines should be followed if available. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. However, if the patient is aged over 65 years or has visible or non-visible haematuria, a urine culture should be sent. Pregnant women with UTIs should be treated with nitrofurantoin, amoxicillin, or cefalexin for seven days. Trimethoprim should be avoided during pregnancy as it is teratogenic in the first trimester. Asymptomatic bacteriuria in pregnant women should also be treated to prevent progression to acute pyelonephritis. Men with UTIs should be offered a seven-day course of trimethoprim or nitrofurantoin unless prostatitis is suspected. A urine culture should be sent before antibiotics are started. Catheterised patients should not be treated for asymptomatic bacteria, but if symptomatic, a seven-day course of antibiotics should be given. Acute pyelonephritis requires hospital admission and treatment with a broad-spectrum cephalosporin or quinolone for 10-14 days. Referral to urology is not routinely required for men who have had one uncomplicated lower UTI.

    • This question is part of the following fields:

      • Renal Medicine/Urology
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  • Question 16 - A 55-year-old man presented to his GP with two instances of painless visible...

    Incorrect

    • A 55-year-old man presented to his GP with two instances of painless visible haematuria. He was subsequently referred to urology for biopsy and flexible cystoscopy, which revealed a transitional cell carcinoma of the bladder. What is the most significant risk factor associated with this condition?

      Your Answer: Male sex

      Correct Answer: Smoking

      Explanation:

      Risk Factors for Bladder Cancer

      Bladder cancer is a type of cancer that affects the bladder, and there are different types of bladder cancer. The most common type is urothelial (transitional cell) carcinoma, and the risk factors for this type of bladder cancer include smoking, exposure to aniline dyes, rubber manufacture, and cyclophosphamide. Smoking is the most important risk factor in western countries, with a hazard ratio of around 4. Exposure to aniline dyes, such as working in the printing and textile industry, can also increase the risk of bladder cancer. Rubber manufacture and cyclophosphamide are also risk factors for urothelial carcinoma.

      On the other hand, squamous cell carcinoma of the bladder has different risk factors. Schistosomiasis and smoking are the main risk factors for this type of bladder cancer. Schistosomiasis is a parasitic infection that can cause inflammation and damage to the bladder, which can increase the risk of developing squamous cell carcinoma. Smoking is also a risk factor for squamous cell carcinoma, as it can cause changes in the cells of the bladder lining that can lead to cancer.

      In summary, the risk factors for bladder cancer depend on the type of cancer. Urothelial carcinoma is mainly associated with smoking, exposure to aniline dyes, rubber manufacture, and cyclophosphamide, while squamous cell carcinoma is mainly associated with schistosomiasis and smoking. It is important to be aware of these risk factors and take steps to reduce your risk of developing bladder cancer.

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      • Renal Medicine/Urology
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  • Question 17 - Which of the following statements best describes bladder cancer? ...

    Incorrect

    • Which of the following statements best describes bladder cancer?

      Your Answer: At diagnosis, most tumours have invaded the muscle of the bladder wall.

      Correct Answer: Survival correlates well with TNM staging at diagnosis.

      Explanation:

      Bladder Cancer: Prognostic Factors, Staging, and Treatment Options

      Bladder cancer is a common malignancy that affects the urinary system. Survival rates are closely linked to the TNM staging at diagnosis, with non-muscle invasive bladder cancer having a good prognosis and decreasing survival rates with increasing stage. The most significant prognostic factors for bladder cancer are grade, depth of invasion, and the presence of carcinoma in situ. Chemotherapy for metastatic disease is seldom used and has limited effectiveness. Cisplatin-based chemotherapy regimens are the standard treatment for metastatic bladder cancer, with a median overall patient survival of 13-15 months and a 2-year survival rate of 15-20%. Careful follow-up is necessary for non-muscle invasive bladder cancer due to the high rate of disease recurrence and progression.

    • This question is part of the following fields:

      • Renal Medicine/Urology
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  • Question 18 - Which factors affect water excretion in the kidneys? ...

    Incorrect

    • Which factors affect water excretion in the kidneys?

      Your Answer: Ascending limb of loop of Henle

      Correct Answer: Vasopressin

      Explanation:

      The Renal Tubules: Functions and Regulation

      The kidneys play a crucial role in maintaining the body’s fluid and electrolyte balance. This is achieved through the intricate workings of the renal tubules, which are responsible for filtering and reabsorbing various substances from the blood.

      Vasopressin, also known as antidiuretic hormone, regulates water excretion in the distal convoluted tubule and collecting ducts. Its receptor, vasopressin 2, triggers the insertion of aquaporin-2 channels, allowing water to be reabsorbed down an osmotic gradient.

      The distal convoluted tubule regulates pH by absorbing bicarbonate and secreting protons, as well as controlling sodium and potassium levels through aldosterone-mediated ion transport. It also participates in calcium regulation by reabsorbing it in response to parathyroid hormone.

      The proximal convoluted tubule reabsorbs the majority of ions and water in the urinary space back into the body.

      The ascending limb of the loop of Henle is impermeable to water, but actively reabsorbs sodium, potassium, and chloride ions. This generates a positive electrochemical potential difference in the lumen, driving more paracellular reabsorption of sodium and other cations.

      The collecting ducts continue the work of water reabsorption and electrolyte balance initiated in the collecting tubules. Progenitor cells within the collecting duct epithelium respond to tubular injury by proliferating and expanding the principal cell population to maintain epithelial integrity, or by committing to a myofibroblastic phenotype and forming peritubular collars in response to increased intraluminal pressure.

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      • Renal Medicine/Urology
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  • Question 19 - A 72 year old man presents with a 6 day history of vomiting...

    Incorrect

    • A 72 year old man presents with a 6 day history of vomiting and diarrhoea. His blood results show Na+ 142 mmol/l, K+ 5.9 mmol/l, urea 14 mmol/l, and creatinine 320 mmol/l. His renal function was normal on routine blood tests 2 months ago. What finding is most indicative of acute tubular necrosis in this patient?

      Your Answer: Postural drop of >20 mmHg

      Correct Answer: Raised urinary sodium

      Explanation:

      The patient is experiencing acute kidney injury, which can be categorized into three causes: pre-renal, renal, and post-renal. Pre-renal causes are due to inadequate renal perfusion, such as dehydration, haemorrhage, heart failure, or sepsis. In this case, the kidneys are still able to concentrate urine and retain sodium, resulting in high urine osmolality and low urine sodium. Renal causes are most commonly caused by acute tubular necrosis, which damages tubular cells due to prolonged ischaemia or toxins. In this scenario, the kidneys are unable to concentrate urine or retain sodium, leading to low urine osmolality and high urine sodium. Acute glomerulonephritis and acute interstitial nephritis are rarer causes of renal injury. Post-renal causes are due to obstruction of the urinary tract, which can be identified through hydronephrosis on renal ultrasound.

      Distinguishing between Acute Tubular Necrosis and Prerenal Uraemia in Acute Kidney Injury

      Acute kidney injury can be caused by various factors, including prerenal uraemia and acute tubular necrosis. It is important to distinguish between the two in order to provide appropriate treatment. Prerenal uraemia occurs when the kidneys hold on to sodium to preserve volume, leading to decreased blood flow to the kidneys. On the other hand, acute tubular necrosis is caused by damage to the kidney tubules, often due to ischemia or toxins.

      To differentiate between the two, several factors can be considered. In prerenal uraemia, urine sodium levels are typically less than 20 mmol/L, while in acute tubular necrosis, they are usually greater than 40 mmol/L. Urine osmolality is also a useful indicator, with levels above 500 mOsm/kg suggesting prerenal uraemia and levels below 350 mOsm/kg suggesting acute tubular necrosis.

      Fractional sodium excretion and fractional urea excretion are also important measures. In prerenal uraemia, the fractional sodium excretion is typically less than 1%, while in acute tubular necrosis, it is usually greater than 1%. Similarly, the fractional urea excretion is less than 35% in prerenal uraemia and greater than 35% in acute tubular necrosis.

      Other factors that can help distinguish between the two include response to fluid challenge, serum urea:creatinine ratio, urine:plasma osmolality, urine:plasma urea ratio, and specific gravity. By considering these factors, healthcare providers can accurately diagnose and treat acute kidney injury.

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      • Renal Medicine/Urology
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  • Question 20 - A 30-year-old woman with a family history of renal disease presents with gross...

    Correct

    • A 30-year-old woman with a family history of renal disease presents with gross haematuria. She reports that her sister recently underwent a kidney transplant and that her mother passed away due to renal failure. During physical examination, a significant mass is palpated in the left lumbar region, and a smaller mass is felt in the right flank. Elevated levels of blood urea and serum creatinine are observed.
      What is the most likely diagnosis?

      Your Answer: Adult polycystic kidney disease

      Explanation:

      Common Kidney Disorders and their Clinical Presentations

      Autosomal Dominant Polycystic Kidney Disease (ADPKD)
      ADPKD is a progressive disorder characterized by cyst formation and enlargement in the kidney and other organs. Patients may experience pain in the abdomen, flank or back, and hypertension is a common early manifestation. Palpable, bilateral flank masses are present in advanced ADPKD.

      Renal Cell Carcinoma (RCC)
      RCC is the most common type of kidney cancer in adults. It may remain clinically occult for most of its course, with only 10% of patients presenting with the classic triad of flank pain, haematuria, and unilateral palpable flank mass. RCC presents with hypercalcaemia manifestations in 5% of cases and with varicocele in 2% of men.

      Renal Calculi
      Renal calculi, or nephrolithiasis, classically present with sudden onset of severe pain originating in the flank and radiating inferiorly and anteriorly. On examination, there is dramatic costovertebral angle tenderness.

      Prostatic Carcinoma
      Most cases of prostate cancer are identified by screening in asymptomatic men. Symptoms include urinary complaints or retention, back pain, and haematuria. Findings in patients with advanced disease include bony tenderness, lower-extremity oedema or deep venous thrombosis, and an overdistended bladder due to outlet obstruction.

      Renal Amyloidosis
      Patients with renal amyloidosis typically present with proteinuria and/or hypertension, followed by progressive renal failure. Haematuria is not a feature.

      Clinical Presentations of Common Kidney Disorders

    • This question is part of the following fields:

      • Renal Medicine/Urology
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  • Question 21 - A 43-year-old lady with hypertension managed on ramipril undergoes annual review.
    Her bloods are...

    Incorrect

    • A 43-year-old lady with hypertension managed on ramipril undergoes annual review.
      Her bloods are shown below:
      Last year This year Reference range
      Sodium (Na+) 134 133 135-145 mEq/l
      Potassium (K+) 3.7 4.1 3.5-5.0 mEq/l
      Creatinine (Cr) 84 96 44-97 μmol/l
      Estimated glomerular filtration rate (eGFR) >90 79 >90 ml/min/1.73 m2
      Based on these results, what should be the next step?

      Your Answer: Stop ramipril immediately

      Correct Answer: Continue current dose

      Explanation:

      Management of Renal Function Changes in Patients on Renin-Angiotensin System Antagonists

      When a patient on renin-angiotensin system antagonists, such as ramipril, experiences a slight decrease in estimated glomerular filtration rate (eGFR) or an increase in serum creatinine, current National Institute for Health and Care Excellence (NICE) guidelines recommend continuing the current dose and repeating the test in 1-2 weeks if the change is <25% in eGFR or <30% in serum creatinine at baseline. Referral to a renal specialist is not necessary unless there are specific indications. It is not recommended to reduce or stop the dose of ramipril in this situation as it may lead to poorly controlled hypertension and increased cardiovascular risk. Renal ultrasound is only indicated for selected groups of patients with chronic kidney disease.

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      • Renal Medicine/Urology
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  • Question 22 - An 83-year-old woman is admitted to the hospital feeling generally unwell. She has...

    Incorrect

    • An 83-year-old woman is admitted to the hospital feeling generally unwell. She has also developed a fever and diffuse erythematous rash over the last few days. Urinalysis is positive for blood and protein, and blood tests show raised eosinophils and creatinine. Her General Practitioner started her on a new medication for a painful and swollen knee joint two weeks ago, but she cannot remember the name or what it was for.
      Which of the following drugs would be safe to continue at present, given the suspected diagnosis?

      Your Answer: Amoxicillin

      Correct Answer: Prednisolone

      Explanation:

      Common Medications and their Association with Acute Tubulointerstitial Nephritis

      Acute tubulointerstitial nephritis is a condition characterized by inflammation of the renal tubules and interstitium, often caused by medications. Here are some common medications and their association with acute tubulointerstitial nephritis:

      1. Prednisolone: This medication is safe to continue as it is already used as a management option for acute tubulointerstitial nephritis.

      2. Allopurinol: This medication should be discontinued as it is known to cause acute tubulointerstitial nephritis.

      3. Amoxicillin: This beta-lactam antibiotic is one of the most common drug-related causes of acute tubulointerstitial nephritis and may need to be withdrawn.

      4. Diclofenac: Non-steroidal anti-inflammatory drugs, such as diclofenac, are another common cause of tubulointerstitial nephritis and should be stopped in any form of acute kidney injury.

      5. Omeprazole: Proton pump inhibitors, such as omeprazole, are known to be a triggering medication for acute tubulointerstitial nephritis and should be withdrawn promptly to allow for renal function recovery.

      It is important to be aware of these associations and to monitor patients for symptoms of acute tubulointerstitial nephritis when prescribing these medications.

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      • Renal Medicine/Urology
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  • Question 23 - A 25-year-old man presents with a complaint of generalised swelling that has affected...

    Correct

    • A 25-year-old man presents with a complaint of generalised swelling that has affected his legs, arm and face, worsening over the last three weeks. Upon investigation, the following results were obtained: Sodium (Na+) 139 mmol/l (normal range: 135–145 mmol/l), Potassium (K+) 4.2 mmol/l (normal range: 3.5–5.0 mmol/l), Creatinine (Cr) 190 μmol/l (normal range: 50–120 μmol/l), Urea 14.8 mmol/l (normal range: 7–20 mmol/l), Alanine aminotransferase (ALT) 20 IU/l (normal range: 29–33 IU/l), Bilirubin 16 μmol/l (normal range: < 20.5 μmol/l), Albumin 19 g/l (normal range: 35–50 g/l), Total Cholesterol 9.2 mmol/l (normal range: < 5.2 mmol/l), Prothrombin time (PT) 10 s. What is the most likely diagnosis?

      Your Answer: Nephrotic syndrome

      Explanation:

      Differential Diagnosis for a Patient with Generalized Edema, Low Albumin, Renal Impairment, and Elevated Cholesterol

      The patient presents with generalized edema, low albumin, renal impairment, and elevated cholesterol. The most likely diagnosis is nephrotic syndrome. Anorexia nervosa is unlikely to cause such a low albumin level. Cirrhosis of the liver is less likely due to normal liver function tests and PT. Cystic fibrosis typically presents with bronchiectasis, pancreatic insufficiency, malabsorption, or diabetes. Nephritic syndrome causes hypertension, haematuria, and oliguria.

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      • Renal Medicine/Urology
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  • Question 24 - A 56-year-old man is admitted to the hospital with a high stoma output...

    Incorrect

    • A 56-year-old man is admitted to the hospital with a high stoma output from his ileostomy. He had a colectomy 8 years ago due to severe ulcerative colitis. He complains of leg cramps and occasional palpitations, and feels weak. Upon examination, his abdomen is soft with slight tenderness throughout. His blood work reveals a sodium level of 138 mmol/l, potassium level of 2.2 mmol/l, urea level of 13.3 mmol/l, and creatinine level of 150 µmol/l. An ECG shows flattened T waves and U waves. He is admitted to the medical admission unit. How should his electrolyte imbalance be managed?

      Your Answer: Transfer to high care area with cardiac monitoring, central line insertion, 3 bags of 100ml 0.9% Saline with 40mmol KCL per bag over 1 hour

      Correct Answer: Transfer to high care area with cardiac monitoring, 3 x 1litre bags of 0.9% saline with 40mmol KCL per bag over 24 hours.

      Explanation:

      Understanding Hypokalaemia and its Features

      Hypokalaemia is a medical condition characterized by low levels of potassium in the blood. It can lead to various symptoms, including muscle weakness and hypotonia. Patients with hypokalaemia who are also taking diuretics should be monitored closely for digoxin toxicity.

      One of the most significant concerns with hypokalaemia is its impact on the heart. ECG features associated with hypokalaemia include U waves, small or absent T waves, prolonged PR interval, and ST depression. These changes can increase the risk of arrhythmias and other cardiac complications.

      It is essential to recognize the signs and symptoms of hypokalaemia promptly. Treatment may involve potassium supplements or addressing the underlying cause of the condition. With proper management, patients with hypokalaemia can avoid complications and improve their overall health.

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      • Renal Medicine/Urology
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  • Question 25 - A 68-year-old man with a history of heart failure and type 2 diabetes...

    Incorrect

    • A 68-year-old man with a history of heart failure and type 2 diabetes mellitus is being seen in the diabetes clinic. He is currently taking furosemide 40 mg od, ramipril 10mg od, and bisoprolol 5mg od. On clinical examination, there is no evidence of peripheral edema, a clear chest, and his blood pressure is 130/76 mmHg. Recent renal and liver function tests are normal. Which of the following medications is contraindicated?

      Your Answer:

      Correct Answer: Pioglitazone

      Explanation:

      Heart failure is a complete contraindication for the use of pioglitazone and other thiazolidinediones.

      Thiazolidinediones: A Class of Diabetes Medications

      Thiazolidinediones are a type of medication used to treat type 2 diabetes. They work by activating the PPAR-gamma receptor, which reduces insulin resistance in the body. However, one medication in this class, rosiglitazone, was withdrawn in 2010 due to concerns about its cardiovascular side effects.

      The PPAR-gamma receptor is a nuclear receptor found inside cells. It is naturally activated by free fatty acids and is involved in regulating the differentiation and function of adipocytes (fat cells).

      While thiazolidinediones can be effective in treating diabetes, they can also have adverse effects. Patients may experience weight gain, liver impairment (which requires monitoring of liver function tests), and fluid retention. Thiazolidinediones are contraindicated in patients with heart failure due to the increased risk of fluid retention, especially if the patient is also taking insulin. Recent studies have also shown an increased risk of fractures and bladder cancer in patients taking pioglitazone, another medication in this class.

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      • Renal Medicine/Urology
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  • Question 26 - A 26-year-old woman is recuperating from a kidney transplant. Within 24 hours of...

    Incorrect

    • A 26-year-old woman is recuperating from a kidney transplant. Within 24 hours of the surgery, she complains of increased discomfort at the transplant site. Upon examination, she has a fever, tenderness at the transplant site, and has not produced urine since the procedure. Her creatinine levels have significantly increased in the past 24 hours. What is the fundamental mechanism behind her rejection?

      Your Answer:

      Correct Answer: Pre-existing antibodies against ABO or HLA antigens

      Explanation:

      Understanding HLA Typing and Graft Failure in Renal Transplants

      The human leucocyte antigen (HLA) system, also known as the major histocompatibility complex (MHC), is located on chromosome 6 and plays a crucial role in renal transplants. The HLA system includes class 1 antigens (A, B, and C) and class 2 antigens (DP, DQ, and DR), with DR being the most important for HLA matching in renal transplants. Graft survival rates for cadaveric transplants are 90% at 1 year and 60% at 10 years, while living-donor transplants have a 95% survival rate at 1 year and 70% at 10 years.

      Post-operative problems may include acute tubular necrosis of the graft, vascular thrombosis, urine leakage, and urinary tract infections. Hyperacute rejection, which occurs within minutes to hours, is caused by pre-existing antibodies against ABO or HLA antigens and leads to widespread thrombosis of graft vessels, resulting in the need for graft removal. Acute graft failure, which occurs within 6 months, is usually due to mismatched HLA and is picked up by a rising creatinine, pyuria, and proteinuria. Chronic graft failure, which occurs after 6 months, is caused by both antibody and cell-mediated mechanisms and leads to fibrosis of the transplanted kidney, with recurrence of the original renal disease being a common cause.

      In summary, understanding the HLA system and its role in renal transplants is crucial for successful outcomes. Monitoring for post-operative problems and early detection of graft failure can help improve long-term survival rates.

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      • Renal Medicine/Urology
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  • Question 27 - A 25-year-old man with a family history of autosomal-dominant polycystic kidneys has been...

    Incorrect

    • A 25-year-old man with a family history of autosomal-dominant polycystic kidneys has been diagnosed with polycystic kidneys using ultrasound. He is currently asymptomatic and has no other past medical history.
      What is the most crucial factor to manage for improving his long-term prognosis?

      Your Answer:

      Correct Answer:

      Explanation:

      Managing Polycystic Kidney Disease: Key Factors for Improving Long-Term Outcomes

      Polycystic kidney disease (PKD) is a genetic disorder that affects the kidneys, causing the growth of multiple cysts that can lead to kidney failure. To improve the long-term outcomes of patients with PKD, it is crucial to control blood pressure, which is the single most important factor. PKD has two main types, PKD1 and PKD2, with PKD1 being more common. Complications of PKD include haematuria, nocturia, hypertension, and loin pain. Prognosis varies, with PKD1 patients requiring dialysis or transplantation by the age of 60, while PKD2 patients may not require it until the age of 75. While there is limited evidence that decreasing protein and caffeine intake, increasing exercise, and stopping alcohol consumption may improve long-term outcomes, controlling blood pressure remains the most critical factor in managing PKD.

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      • Renal Medicine/Urology
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  • Question 28 - A 26-year-old man with a family history of adult polycystic kidney disease approaches...

    Incorrect

    • A 26-year-old man with a family history of adult polycystic kidney disease approaches his GP for screening. What would be the most suitable screening test?

      Your Answer:

      Correct Answer: Ultrasound abdomen

      Explanation:

      The recommended screening test for adult polycystic kidney disease is ultrasound, while genetic testing is not yet routinely advised for screening relatives.

      Autosomal dominant polycystic kidney disease (ADPKD) is a prevalent genetic condition that affects approximately 1 in 1,000 Caucasians. The disease is caused by mutations in two genes, PKD1 and PKD2, which produce polycystin-1 and polycystin-2, respectively. ADPKD type 1 accounts for 85% of cases, while ADPKD type 2 accounts for the remaining 15%. Individuals with ADPKD develop multiple fluid-filled cysts in their kidneys, which can lead to renal failure.

      To diagnose ADPKD in individuals with a positive family history, an abdominal ultrasound is typically performed. The diagnostic criteria for ultrasound include the presence of two cysts, either unilateral or bilateral, in individuals under 30 years of age, two cysts in both kidneys for those aged 30-59 years, and four cysts in both kidneys for those over 60 years of age.

      Management of ADPKD may involve the use of tolvaptan, a vasopressin receptor 2 antagonist, for select patients. Tolvaptan has been recommended by NICE as an option for treating ADPKD in adults with chronic kidney disease stage 2 or 3 at the start of treatment, evidence of rapidly progressing disease, and if the company provides it with the agreed discount in the patient access scheme. The goal of treatment is to slow the progression of cyst development and renal insufficiency. An enlarged kidney with extensive cysts is a common finding in individuals with ADPKD.

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      • Renal Medicine/Urology
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  • Question 29 - What is one of the most important functions of the proximal convoluted tubule...

    Incorrect

    • What is one of the most important functions of the proximal convoluted tubule (PCT)?

      Your Answer:

      Correct Answer: Sodium reabsorption

      Explanation:

      Functions of the Proximal Convoluted Tubule in the Nephron

      The proximal convoluted tubule (PCT) is a crucial part of the nephron, responsible for several important functions. One of its primary roles is the reabsorption of sodium, which occurs through active transport facilitated by the numerous mitochondria in the epithelial cells. This creates a concentration gradient that allows for the passive reabsorption of water. Glucose is also reabsorbed in the PCT through secondary active transport, driven by the sodium gradient. The PCT also regulates the pH of the filtrate by exchanging hydrogen ions for bicarbonate ions. Additionally, the PCT is the primary site for ammoniagenesis, which involves the breakdown of glutamine to α-ketoglutarate. Finally, the regulation of urine concentration occurs in the distal convoluted tubule and collecting duct under the influence of vasopressin.

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      • Renal Medicine/Urology
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  • Question 30 - Which of the following statements is true for prostate cancer? ...

    Incorrect

    • Which of the following statements is true for prostate cancer?

      Your Answer:

      Correct Answer: There is currently no screening programme for prostate cancer in the UK.

      Explanation:

      Prostate Cancer: Facts and Controversies

      Prostate cancer is the second most common cancer in men in developed countries, with an estimated one in six men being diagnosed with it in their lifetime. However, there is currently no screening programme for prostate cancer in the UK due to the controversial nature of PSA testing. PSA tests can yield unreliable results and may lead to unnecessary treatment for slow-growing tumours that may never cause symptoms or shorten life. Although treating prostate cancer in its early stages can be beneficial, the potential side effects of treatment may cause men to delay treatment until it is absolutely necessary.

      The 5-year relative survival rates for prostate cancer vary depending on the stage of the cancer at diagnosis, with local or regional prostate cancer having a survival rate of over 99%, while distant disease has a survival rate of 29%. The Gleason grade, tumour volume, and presence of capsular penetration or margin positivity are important indicators of prognosis for prostate cancer.

      Prostate cancer is also the second most common cause of cancer death in men, accounting for 8% of cancer deaths. Advanced prostate cancer may not involve pain, but can result in a range of symptoms including weight loss, anorexia, bone pain, neurological deficits, and lower extremity pain and oedema.

      Overall, prostate cancer remains a complex and controversial disease, with ongoing debates surrounding screening and treatment options.

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      • Renal Medicine/Urology
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  • Question 31 - A 38-year-old man with a history of Wilson’s disease and mild osteoarthritis presents...

    Incorrect

    • A 38-year-old man with a history of Wilson’s disease and mild osteoarthritis presents with features of nephrotic syndrome.
      Which medication is the most likely cause for his condition?

      Your Answer:

      Correct Answer: d-Penicillamine

      Explanation:

      Pharmacologic Treatments and Complications: A Review

      Secondary membranous nephropathy can be caused by autoimmune diseases, infectious diseases, malignancy, and exposure to certain drugs such as captopril, gold, lithium, or penicillamine. Treatment with chelating agents like D-penicillamine is the mainstay of treatment for Wilson’s disease, but it can cause proteinuria in up to 30% of patients. Hydroxychloroquine is used for active rheumatoid arthritis but can cause ocular toxicity. Methotrexate is used for severe Crohn’s disease and rheumatoid arthritis but can cause bone marrow suppression. Topical NSAIDs are unlikely to cause systemic side-effects, while sulfasalazine can cause rare but serious side-effects in patients with G6PD deficiency. It is important to monitor patients closely for complications when using these pharmacologic treatments.

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      • Renal Medicine/Urology
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  • Question 32 - As a foundation doctor in general surgery, you are assisting your consultant in...

    Incorrect

    • As a foundation doctor in general surgery, you are assisting your consultant in a surgical exploration of a suspected testicular torsion in a patient with a bell clapper deformity. The patient, who is in his early twenties, has been experiencing symptoms for six hours. Upon examination, the surgery confirms the presence of testicular torsion.

      What is the appropriate course of action for the surgeon to take in this situation?

      Your Answer:

      Correct Answer: Fixation of both testicles

      Explanation:

      To prevent future torsion of the other testicle, it is recommended that both testes be fixed during testicular torsion surgery. While manual rotation may be successful in some cases, it is not appropriate once surgery has begun. If a bell clapper deformity is present, both testes should be fixed if they are still viable. Given the short duration of symptoms (only six hours), it is unlikely that surgical removal (orchiectomy) will be necessary.

      Testicular Torsion: Causes, Symptoms, and Treatment

      Testicular torsion is a medical condition that occurs when the spermatic cord twists, leading to testicular ischaemia and necrosis. This condition is most common in males aged between 10 and 30, with a peak incidence between 13 and 15 years. The symptoms of testicular torsion are sudden and severe pain, which may be referred to the lower abdomen. Nausea and vomiting may also be present. On examination, the affected testis is usually swollen, tender, and retracted upwards, with reddened skin. The cremasteric reflex is lost, and elevation of the testis does not ease the pain (Prehn’s sign).

      The treatment for testicular torsion is urgent surgical exploration. If a torted testis is identified, both testes should be fixed, as the condition of bell clapper testis is often bilateral.

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      • Renal Medicine/Urology
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  • Question 33 - A 45-year-old non-smoker with hypertension and diabetes has been diagnosed with bilateral renal...

    Incorrect

    • A 45-year-old non-smoker with hypertension and diabetes has been diagnosed with bilateral renal artery stenosis. Blood tests reveal that he has normal renal function. He has undergone percutaneous angioplasty to both renal arteries, which was unsuccessful.
      Which medication should this patient be started on?

      Your Answer:

      Correct Answer: Start angiotensin-converting enzyme (ACE) inhibitors

      Explanation:

      Medical Management of Renal Artery Stenosis

      Renal artery stenosis is a condition that requires medical management to control hypertension. Even if the arteries are treated successfully with angioplasty, antihypertensive therapy should be initiated. The ideal agent for this purpose is one that blocks the renin-angiotensin-aldosterone system, such as angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs). Warfarin is not indicated in patients with renal artery stenosis, but may be used for prophylaxis of embolisation in other conditions. Clopidogrel is not indicated for hypertension management in renal artery stenosis. Statins may be used for primary prevention of cardiovascular disease if cholesterol levels are raised, but controlling blood pressure is the primary consideration in renal artery stenosis. Spironolactone should not be used in patients with renal compromise. Control of blood pressure should ideally be achieved using ACE inhibitors or ARBs.

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      • Renal Medicine/Urology
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  • Question 34 - A 68-year-old psychiatric patient is brought to the Emergency Room, complaining of excessive...

    Incorrect

    • A 68-year-old psychiatric patient is brought to the Emergency Room, complaining of excessive thirst. He is carrying multiple shopping bags and has spent a significant amount of money. Blood tests reveal a urea level of 20.5 mmol/l (reference range 2.5–7.1 mmol/l), a creatinine level of 190 μmol/l (reference range 53–106 μmol/l) and a sodium level of 144 mmol/l (reference range 135–145 mmol/l). Urinary osmolality is low.
      What is the most likely diagnosis based on this clinical presentation?

      Your Answer:

      Correct Answer: Nephrogenic diabetes insipidus (DI)

      Explanation:

      Medical Conditions Explained: Nephrogenic Diabetes Insipidus, Cranial Diabetes Insipidus, Chronic Reflux Nephropathy, Syndrome of Inappropriate Antidiuretic Hormone Secretion, and Psychogenic Polydipsia

      Nephrogenic Diabetes Insipidus (DI)
      Nephrogenic DI is a condition where the kidneys are unable to concentrate urine due to resistance to the action of antidiuretic hormone (ADH). This can be caused by lithium toxicity, which is commonly used to treat bipolar affective disorder. Symptoms include passing large volumes of dilute urine and a urinary specific gravity of 1.005 or less. Treatment involves replacing fluid losses with dextrose and water or hypo-osmolar intravenous fluids, as well as a low-protein, low-sodium diet. Alternative medication to lithium may be considered after consultation with a psychiatrist.

      Cranial Diabetes Insipidus
      Cranial DI, also known as central or neurogenic DI, is caused by decreased secretion of ADH, resulting in polyuria and polydipsia. Urine osmolality will be less than 300 mOsm/kg after a water deprivation test, and will rise to over 750 mOsm/kg after ADH administration.

      Chronic Reflux Nephropathy
      Reflux nephropathy is a condition where urine flows back from the bladder to the kidneys, causing renal damage. It is typically seen in children with urinary tract abnormalities, but can also occur with conditions that obstruct urine flow. Symptoms include those of nephrotic syndrome and urinary tract infections, but this diagnosis is not consistent with the clinical presentation in this scenario.

      Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)
      SIADH is characterized by hyponatremia and hypo-osmolality due to excessive secretion or action of ADH, resulting in impaired water excretion. However, the patient in this scenario is presenting with hypernatremia, which is not consistent with SIADH.

      Psychogenic Polydipsia
      Psychogenic polydipsia is excessive fluid intake without physiological stimuli, often caused by psychiatric disorders such as schizophrenia or bipolar affective disorder. It is accompanied by the sensation of dry mouth.

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  • Question 35 - A 21-year-old male patient visits his GP complaining of visible blood in his...

    Incorrect

    • A 21-year-old male patient visits his GP complaining of visible blood in his urine for the past day. He reports no pain while urinating or abdominal pain. He has no significant medical history and is not taking any regular medications. He had a mild cold four days ago. Upon analysis, his urine shows positive for blood and trace amounts of protein, but negative for leucocytes, nitrites, and glucose. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: IgA nephropathy

      Explanation:

      The classic presentation of IgA nephropathy is visible haematuria that occurs after a recent upper respiratory tract infection. This patient’s new-onset haematuria following a recent URTI is consistent with a diagnosis of IgA nephropathy, which is the most common cause of haematuria worldwide. IgA nephropathy typically presents acutely in young males, in contrast to post-streptococcal glomerulonephritis, which presents after 2 weeks from an upper or lower respiratory tract infection. Focal segmental glomerulosclerosis and minimal change disease are unlikely diagnoses as they present with proteinuria rather than haematuria. While post-streptococcal glomerulonephritis is a possible differential diagnosis, it differs from this patient’s presentation as it typically presents with haematuria after 2 weeks following an acute infection.

      Understanding IgA Nephropathy

      IgA nephropathy, also known as Berger’s disease, is the most common cause of glomerulonephritis worldwide. It is characterized by the deposition of IgA immune complexes in the mesangium, leading to mesangial hypercellularity and positive immunofluorescence for IgA and C3. The classic presentation is recurrent episodes of macroscopic hematuria in young males following an upper respiratory tract infection. Unlike post-streptococcal glomerulonephritis, IgA nephropathy is not associated with low complement levels and typically does not present with nephrotic range proteinuria or renal failure.

      Management of IgA nephropathy depends on the severity of proteinuria and renal function. Isolated hematuria with no or minimal proteinuria and normal GFR requires only follow-up to monitor renal function. Persistent proteinuria with normal or slightly reduced GFR can be treated with ACE inhibitors. If there is active disease or failure to respond to ACE inhibitors, immunosuppression with corticosteroids may be necessary. The prognosis of IgA nephropathy varies, with 25% of patients developing ESRF. Factors associated with a poor prognosis include male gender, proteinuria, hypertension, smoking, hyperlipidemia, and ACE genotype DD, while frank hematuria is a marker of good prognosis.

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  • Question 36 - You are evaluating a 67-year-old patient in the renal clinic who has been...

    Incorrect

    • You are evaluating a 67-year-old patient in the renal clinic who has been undergoing haemodialysis for chronic kidney disease for the last 6 years. What is the leading cause of mortality in this patient population?

      Your Answer:

      Correct Answer: Ischaemic heart disease

      Explanation:

      Causes of Chronic Kidney Disease

      Chronic kidney disease is a condition that affects the kidneys, causing them to gradually lose their ability to function properly. There are several common causes of this condition, including diabetic nephropathy, chronic glomerulonephritis, chronic pyelonephritis, hypertension, and adult polycystic kidney disease.

      Diabetic nephropathy is a complication of diabetes that occurs when high blood sugar levels damage the small blood vessels in the kidneys. Chronic glomerulonephritis is a condition in which the glomeruli, the tiny filters in the kidneys, become inflamed and damaged over time. Chronic pyelonephritis is a type of kidney infection that can cause scarring and damage to the kidneys. Hypertension, or high blood pressure, can also damage the kidneys over time. Finally, adult polycystic kidney disease is an inherited condition in which cysts form in the kidneys, causing them to enlarge and lose function.

      It is important to identify the underlying cause of chronic kidney disease in order to properly manage the condition and prevent further damage to the kidneys. Treatment may involve medications, lifestyle changes, and in some cases, dialysis or kidney transplant.

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      • Renal Medicine/Urology
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  • Question 37 - A 72-year-old man with chronic kidney disease is in his seventh year of...

    Incorrect

    • A 72-year-old man with chronic kidney disease is in his seventh year of haemodialysis (HD). He visits his general practitioner with symptoms of pain, numbness and tingling in both hands during the early hours of the morning. He also complains of stiffness in his shoulders, hips and knees.
      What diagnosis fits best with this clinical picture?

      Your Answer:

      Correct Answer: Dialysis amyloidosis

      Explanation:

      Differentiating between potential causes of joint pain: A brief overview

      Joint pain can be caused by a variety of conditions, making it important to differentiate between potential causes in order to provide appropriate treatment. Here, we will briefly discuss some of the conditions that may cause joint pain and their distinguishing features.

      Dialysis amyloidosis, also known as beta-2-microglobulin (β-2m) amyloidosis, is a rare condition that affects patients undergoing long-term hemodialysis or continuous ambulatory peritoneal dialysis. It is characterized by the accumulation of β-2m, a major constituent of amyloid fibrils, which can invade synovial membranes and osteoarticular sites, causing destructive osteoarthropathies. Symptomatic relief can be provided with medication, therapy, and surgical procedures, but renal transplantation is the treatment of choice.

      Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease that is generally accepted to be triggered by an external factor, leading to synovial hypertrophy and chronic joint inflammation. Persistent symmetrical polyarthritis of the hands and feet is the hallmark feature of the disease.

      Diabetic neuropathy is the most common complication of diabetes mellitus, affecting up to 50% of patients with type 1 and type 2 disease. It involves symptoms or signs of peripheral nerve dysfunction in people with diabetes, after other possible causes have been excluded.

      Seronegative arthritis is characterized by joint pain and inflammation in the absence of serum rheumatoid factor (RF), which is present in approximately 60-80% of patients with RA.

      Uraemic neuropathy is a distal sensorimotor polyneuropathy caused by uraemic toxins, which is strongly correlated with the severity of renal insufficiency. Typical symptoms include a tingling and pricking sensation in the lower extremities.

      By understanding the distinguishing features of these conditions, healthcare providers can more accurately diagnose and treat joint pain in their patients.

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      • Renal Medicine/Urology
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  • Question 38 - A 47-year-old man comes to the clinic complaining of fatigue. Upon examination, his...

    Incorrect

    • A 47-year-old man comes to the clinic complaining of fatigue. Upon examination, his blood pressure is found to be 190/110 mmHg. Routine blood tests show the following results:
      - Sodium: 145 mmol/L
      - Potassium: 2.5 mmol/L
      - Bicarbonate: 33 mmol/L
      - Urea: 5.6 mmol/L
      - Creatinine: 80 µmol/L

      What is the probable diagnosis?

      Your Answer:

      Correct Answer: Primary hyperaldosteronism

      Explanation:

      Understanding Primary Hyperaldosteronism

      Primary hyperaldosteronism is a medical condition that was previously believed to be caused by an adrenal adenoma, also known as Conn’s syndrome. However, recent studies have shown that bilateral idiopathic adrenal hyperplasia is the cause in up to 70% of cases. It is important to differentiate between the two as this determines the appropriate treatment. Adrenal carcinoma is an extremely rare cause of primary hyperaldosteronism.

      The common features of primary hyperaldosteronism include hypertension, hypokalaemia, and alkalosis. Hypokalaemia can cause muscle weakness, but this is seen in only 10-40% of patients. To diagnose primary hyperaldosteronism, the 2016 Endocrine Society recommends a plasma aldosterone/renin ratio as the first-line investigation. This should show high aldosterone levels alongside low renin levels due to negative feedback from sodium retention caused by aldosterone.

      If the plasma aldosterone/renin ratio is high, a high-resolution CT abdomen and adrenal vein sampling are used to differentiate between unilateral and bilateral sources of aldosterone excess. If the CT is normal, adrenal venous sampling (AVS) can be used to distinguish between unilateral adenoma and bilateral hyperplasia. The management of primary hyperaldosteronism depends on the underlying cause. Adrenal adenoma is treated with surgery, while bilateral adrenocortical hyperplasia is treated with an aldosterone antagonist such as spironolactone.

      In summary, primary hyperaldosteronism is a medical condition that can be caused by adrenal adenoma, bilateral idiopathic adrenal hyperplasia, or adrenal carcinoma. It is characterized by hypertension, hypokalaemia, and alkalosis. Diagnosis involves a plasma aldosterone/renin ratio, high-resolution CT abdomen, and adrenal vein sampling. Treatment depends on the underlying cause and may involve surgery or medication.

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  • Question 39 - A 67-year-old man with a history of multiple myeloma complains of confusion, abdominal...

    Incorrect

    • A 67-year-old man with a history of multiple myeloma complains of confusion, abdominal pain, and excessive thirst. The following blood results are available:
      - Sodium: 145 mmol/L
      - Potassium: 4.1 mmol/L
      - Albumin: 35 g/L
      - Calcium: 3.55 mmol/L
      - Alkaline phosphatase: 120 IU/L
      - Urea: 7.2 mmol/L
      - Creatinine: 130 µmol/L
      What is the primary initial approach to managing his symptoms?

      Your Answer:

      Correct Answer: IV 0.9% saline

      Explanation:

      In patients with hypercalcaemia, the initial treatment is IV fluid therapy. The man’s hypercalcaemia is caused by multiple myeloma, and he is experiencing polydipsia. Additionally, his sodium levels are nearing the upper limit of normal, indicating that he may be dehydrated.

      Managing Hypercalcaemia

      Hypercalcaemia is a condition where there is an excess of calcium in the blood. The initial management of hypercalcaemia involves rehydration with normal saline, typically 3-4 litres per day. This helps to flush out the excess calcium from the body. Once rehydration is achieved, bisphosphonates may be used to further lower the calcium levels. These drugs take 2-3 days to work, with maximal effect being seen at 7 days.

      Calcitonin is another option for managing hypercalcaemia. It works quicker than bisphosphonates but is less commonly used due to its short duration of action. Steroids may be used in sarcoidosis, a condition that can cause hypercalcaemia.

      Loop diuretics such as furosemide may also be used in hypercalcaemia, particularly in patients who cannot tolerate aggressive fluid rehydration. However, they should be used with caution as they may worsen electrolyte derangement and volume depletion.

      In summary, the management of hypercalcaemia involves rehydration with normal saline followed by the use of bisphosphonates or other medications depending on the underlying cause of the condition. It is important to monitor electrolyte levels and adjust treatment accordingly to prevent complications.

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  • Question 40 - A 65-year-old woman with type 2 diabetes is found to have an elevated...

    Incorrect

    • A 65-year-old woman with type 2 diabetes is found to have an elevated plasma creatinine of 150 μmol/l (reference range 62–106 μmol/l). Her blood pressure is 170/95 mmHg, and fundoscopy reveals mild hypertensive changes and background diabetic retinopathy. She has a neuroischaemic ulcer on her left foot and no palpable pedal pulses. Urine dipstick is negative, and renal ultrasound shows a 8.5-cm left kidney and a 6.2-cm right kidney, with reduced cortical thickness.
      What is the most likely cause of the renal impairment?

      Your Answer:

      Correct Answer: Renal artery stenosis

      Explanation:

      Common Causes of Renal Dysfunction and Their Clinical Features

      Renal dysfunction can have various causes, and identifying the underlying condition is crucial for appropriate management. Here are some common causes of renal dysfunction and their clinical features:

      Renal artery stenosis (RAS): RAS can lead to renovascular hypertension and renal impairment, especially in older individuals with atherosclerosis or diabetes mellitus. Symptoms may include sudden worsening of hypertension or renal function, and ultrasonography may show kidney size asymmetry. Treatment options include pharmacologic control of hypertension and serum cholesterol levels, as well as surgical or percutaneous revascularisation in selected cases.

      Membranous nephropathy: This is a type of nephrotic syndrome that often presents with oedema and significant proteinuria (>3.5 g/24 h). It is more common in adults and may be asymptomatic in some cases.

      Cholesterol emboli syndrome: This condition may occur after an invasive arterial procedure and is characterised by renal dysfunction, hypertension, and distal ischaemia due to small-vessel occlusion. Livedo reticularis and blue toe syndrome may also be present.

      Diabetic glomerulosclerosis: This is a complication of diabetes mellitus that can cause persistent albuminuria, declining glomerular filtration rate, and elevated blood pressure. Physical findings associated with long-term diabetes may also be present.

      Reflux nephropathy: This condition is caused by the backflow of urine from the bladder to the kidneys and can lead to renal scarring. It is more common in children with urinary tract abnormalities but can also occur in adults with bladder outlet obstruction or neurogenic bladder. Symptoms may include nephrotic syndrome and urinary tract infection.

      In summary, renal dysfunction can have diverse causes and presentations, and a thorough evaluation is necessary to establish the diagnosis and guide appropriate treatment.

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  • Question 41 - A 49 year-old woman visits her doctor complaining of urinary incontinence that has...

    Incorrect

    • A 49 year-old woman visits her doctor complaining of urinary incontinence that has been going on for nine months. Upon examination, her abdomen appears normal and urinalysis results are normal. The doctor diagnoses her with detrusor muscle over-activity and prescribes oxybutynin. What is the mechanism of action of oxybutynin?

      Your Answer:

      Correct Answer: Anti-muscarinic

      Explanation:

      The detrusor muscle’s contraction is regulated by muscarinic cholinergic receptors, and oxybutynin acts as a direct antimuscarinic agent. Sympathetic control, which decreases detrusor muscle activity, is influenced by serotonin and noradrenaline. The bladder does not contain GABAergic or estrogen receptors.

      Understanding Urinary Incontinence: Causes, Classification, and Management

      Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

      Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

      In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

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  • Question 42 - A 35-year-old man visits his primary care physician complaining of dysuria and frequent...

    Incorrect

    • A 35-year-old man visits his primary care physician complaining of dysuria and frequent urination since yesterday. He has also observed that his urine is cloudy and has a foul odor. He has no flank pain and is in good health overall. He has never had these symptoms before. Upon urinalysis, nitrites and leukocytes are detected. What is the most suitable initial treatment?

      Your Answer:

      Correct Answer: Nitrofurantoin for 7 days

      Explanation:

      If a man presents with symptoms of a lower UTI such as dysuria and urinary frequency, and urinalysis confirms the diagnosis with the presence of nitrates and leucocytes, treatment with either trimethoprim or nitrofurantoin is recommended. However, if there is suspicion of prostatitis or an upper UTI, referral to a specialist may be necessary. It is important to note that men require a 7-day course of antibiotics for lower UTIs, and recurrence may require further evaluation by a Urologist. Women, on the other hand, may be treated with a 3-day course of antibiotics for lower UTIs.

      Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. The management of UTIs depends on various factors such as the patient’s age, gender, and pregnancy status. For non-pregnant women, local antibiotic guidelines should be followed if available. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. However, if the patient is aged over 65 years or has visible or non-visible haematuria, a urine culture should be sent. Pregnant women with UTIs should be treated with nitrofurantoin, amoxicillin, or cefalexin for seven days. Trimethoprim should be avoided during pregnancy as it is teratogenic in the first trimester. Asymptomatic bacteriuria in pregnant women should also be treated to prevent progression to acute pyelonephritis. Men with UTIs should be offered a seven-day course of trimethoprim or nitrofurantoin unless prostatitis is suspected. A urine culture should be sent before antibiotics are started. Catheterised patients should not be treated for asymptomatic bacteria, but if symptomatic, a seven-day course of antibiotics should be given. Acute pyelonephritis requires hospital admission and treatment with a broad-spectrum cephalosporin or quinolone for 10-14 days. Referral to urology is not routinely required for men who have had one uncomplicated lower UTI.

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  • Question 43 - A 55-year-old female patient who visits your clinic regularly presents after routine blood...

    Incorrect

    • A 55-year-old female patient who visits your clinic regularly presents after routine blood tests following the initiation of ramipril for her hypertension. Her clinic BP was 145/98 mmHg before starting ramipril, and her baseline creatinine was 100 umol/L. During her recent visit, her clinic BP was well controlled at 132/84 mmHg, but her creatinine level had increased to 125 umol/L. What is the best course of action for managing her hypertension?

      Your Answer:

      Correct Answer: Continue current dose of ramipril

      Explanation:

      The patient’s renal function is satisfactory, with a GFR of 60 mL/min/1.73m² or higher. The results indicate that the current dose of ramipril has been effective. Therefore, it is recommended to maintain the current dosage of ramipril and follow the standard protocol for monitoring renal function.

      Angiotensin-converting enzyme (ACE) inhibitors are commonly used as the first-line treatment for hypertension and heart failure in younger patients. However, they may not be as effective in treating hypertensive Afro-Caribbean patients. These inhibitors are also used to treat diabetic nephropathy and for secondary prevention of ischaemic heart disease. The mechanism of action of ACE inhibitors is to inhibit the conversion of angiotensin I to angiotensin II. They are metabolized in the liver through phase 1 metabolism.

      ACE inhibitors may cause side effects such as cough, which occurs in around 15% of patients and may occur up to a year after starting treatment. This is thought to be due to increased bradykinin levels. Angioedema may also occur up to a year after starting treatment. Hyperkalaemia and first-dose hypotension are other potential side effects, especially in patients taking diuretics. ACE inhibitors should be avoided during pregnancy and breastfeeding, and caution should be exercised in patients with renovascular disease, aortic stenosis, or hereditary or idiopathic angioedema.

      Patients receiving high-dose diuretic therapy (more than 80 mg of furosemide a day) are at an increased risk of hypotension when taking ACE inhibitors. Before initiating treatment, urea and electrolytes should be checked, and after increasing the dose, a rise in creatinine and potassium may be expected. Acceptable changes include an increase in serum creatinine up to 30% from baseline and an increase in potassium up to 5.5 mmol/l. Patients with undiagnosed bilateral renal artery stenosis may experience significant renal impairment. The current NICE guidelines provide a flow chart for the management of hypertension.

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  • Question 44 - A 52-year-old woman presents to her general practitioner (GP) with symptoms of a...

    Incorrect

    • A 52-year-old woman presents to her general practitioner (GP) with symptoms of a urinary tract infection. There is a history of multiple attendances and a previous neurology referral for migraine. She admits to taking multiple painkillers for her headaches. Blood pressure is 160/90 mmHg. Urinalysis reveals haematuria, and the GP commences her on a 2-week course of nitrofurantoin. She returns, still complaining of symptoms, at which point the presence of a normochromic normocytic anaemia is noted, along with a serum creatinine level of 230 μmol/l (reference range 44–97 μmol/l).
      What diagnosis fits best with this clinical picture?

      Your Answer:

      Correct Answer: Analgesic nephropathy

      Explanation:

      Possible Diagnosis for a Patient with Excessive Analgesic Consumption

      Excessive consumption of analgesic medications such as aspirin and paracetamol can lead to kidney injury, a condition known as analgesic nephropathy. This is caused by decreased blood flow to the kidney, rapid consumption of antioxidants, and subsequent oxidative damage to the kidney, resulting in renal papillary necrosis and chronic interstitial nephritis. The kidney injury may lead to progressive chronic kidney disease, abnormal urinalysis results, hypertension, and normochromic normocytic anaemia.

      Other possible diagnoses for renal damage include reflux nephropathy, acute nephritis, renal failure secondary to sepsis, and hypertensive renal disease. Reflux nephropathy is characterized by renal damage due to the backflow of urine from the bladder towards the kidneys, while acute nephritis is caused by infections or drug-associated hypersensitivity. Renal failure secondary to sepsis is associated with systemic inflammatory response syndrome, and hypertensive renal disease is defined by the coexistence of renal arterial vascular disease and hypertension.

      In the given clinical scenario, the most likely diagnosis is analgesic nephropathy due to the patient’s history of excessive analgesic consumption. However, other diagnoses cannot be ruled out without further evaluation.

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      • Renal Medicine/Urology
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  • Question 45 - A 65-year-old man presents to the emergency department with a 12-day history of...

    Incorrect

    • A 65-year-old man presents to the emergency department with a 12-day history of muscle cramping and fatigue. His blood tests and ECG are as follows:
      - Na+ 140 mmol/L (135 - 145)
      - K+ 3.7 mmol/L (3.5 - 5.0)
      - Bicarbonate 28 mmol/L (22 - 29)
      - Urea 6.2 mmol/L (2.0 - 7.0)
      - Creatinine 95 µmol/L (55 - 120)
      - Calcium 1.7 mmol/L (2.1-2.6)
      - Phosphate 1.3 mmol/L (0.8-1.4)
      - Magnesium 0.62 mmol/L (0.7-1.0)

      The patient's ECG shows a regular sinus rhythm with a rate of 72 BPM and a QTc of 480 ms. What is the most appropriate next step in management?

      Your Answer:

      Correct Answer: Intravenous calcium gluconate

      Explanation:

      A 68-year-old man presents with hypocalcaemia and a prolonged QT interval, which can increase the risk of cardiac arrhythmias such as Torsades de pointes. Urgent intravenous calcium gluconate is the recommended treatment for severe hypocalcaemia, which can cause symptoms such as hand and foot spasming, tetany, and seizures. Checking the vitamin D level is important for identifying the cause of hypocalcaemia, but it is not the next best step in managing this patient’s acute condition. Oral calcium carbonate supplementation may be useful in some cases, but intravenous calcium is the preferred treatment for severe hypocalcaemia. Levothyroxine is not indicated for this patient, as hypothyroidism has not been diagnosed and urgent IV calcium gluconate should be given.

      Understanding Hypocalcaemia: Its Causes and Management

      Hypocalcaemia is a medical condition characterized by low levels of calcium in the blood. It can be caused by various factors such as vitamin D deficiency, chronic kidney disease, hypoparathyroidism, pseudohypoparathyroidism, rhabdomyolysis, magnesium deficiency, massive blood transfusion, and acute pancreatitis. In some cases, contamination of blood samples with EDTA may also lead to falsely low calcium levels.

      To manage severe hypocalcaemia, which may manifest as carpopedal spasm, tetany, seizures, or prolonged QT interval, intravenous calcium replacement is necessary. The preferred method is through the administration of intravenous calcium gluconate, with a recommended dose of 10ml of 10% solution over 10 minutes. However, it is important to note that intravenous calcium chloride may cause local irritation. ECG monitoring is also recommended during the treatment process. Further management of hypocalcaemia depends on the underlying cause.

      In summary, hypocalcaemia is a condition that can be caused by various factors, and its management depends on the severity of the symptoms and the underlying cause. Intravenous calcium replacement is the preferred method for severe cases, and ECG monitoring is recommended during treatment.

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  • Question 46 - A 6-year-old girl presents to the Emergency Department with bloody diarrhoea, vomiting and...

    Incorrect

    • A 6-year-old girl presents to the Emergency Department with bloody diarrhoea, vomiting and fever. Her siblings and parents have also had similar symptoms after attending a birthday party at a local park. Her stool sample is positive for E. Coli and the Paediatric Team are concerned that she has haemolytic uraemic syndrome (HUS) secondary to this infection.
      Which of the following results are most likely to be found if this patient is suffering from HUS?

      Your Answer:

      Correct Answer: Acute renal failure, low platelets, low haemoglobin

      Explanation:

      Haemolytic uraemic syndrome (HUS) is a condition characterized by the simultaneous occurrence of microangiopathic haemolytic anaemia, thrombocytopenia, and acute kidney injury. This set of blood tests shows all three of these symptoms, indicating a possible diagnosis of HUS. HUS is most commonly found in children, with 90% of cases caused by Shiga toxin-producing E. coli. However, a patient with normal renal function and high platelet count is unlikely to have HUS, as low platelet count is a typical symptom. If a patient has ongoing diarrhoea or vomiting due to E. coli infection, they may require intravenous fluids to support their renal function. A raised haemoglobin level is not expected in HUS, as patients usually have reduced haemoglobin due to microangiopathic haemolytic anaemia. Additionally, HUS typically causes thrombocytopenia, not high platelet count. In some cases, children with HUS may require platelet transfusion.

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  • Question 47 - A 75-year-old man has been hospitalized with abdominal discomfort. The surgical team intends...

    Incorrect

    • A 75-year-old man has been hospitalized with abdominal discomfort. The surgical team intends to conduct a contrast-enhanced CT scan, but they are apprehensive due to his stage 3 chronic kidney disease. Below is his most recent renal function:
      Na+ 142 mmol/l
      K+ 4.6 mmol/l
      Urea 8.1 mmol/l
      Creatinine 130 µmol/l
      What is the most crucial measure in decreasing the risk of contrast-induced nephropathy?

      Your Answer:

      Correct Answer: Intravenous 0.9% sodium chloride pre- and post-procedure

      Explanation:

      Contrast Media Nephrotoxicity and Prevention

      Contrast media nephrotoxicity is a condition where there is a 25% increase in creatinine within three days of intravascular administration of contrast media. This condition usually occurs 2-5 days after administration and is caused by various risk factors such as known renal impairment, dehydration, cardiac failure, and the use of nephrotoxic drugs. Procedures such as CT with contrast and coronary angiography/percutaneous coronary intervention (PCI) are examples that may cause contrast-induced nephropathy.

      To prevent contrast-induced nephropathy, intravenous 0.9% sodium chloride at a rate of 1 mL/kg/hour for 12 hours pre- and post-procedure is recommended. Isotonic sodium bicarbonate is also supported by evidence. However, N-acetylcysteine, which was previously given, is now considered ineffective. Patients who are high-risk for contrast-induced nephropathy should have metformin withheld for at least 48 hours and until their renal function has been shown to be normal to avoid the risk of lactic acidosis.

      In summary, contrast media nephrotoxicity is a condition that can occur after the administration of contrast media. It is caused by various risk factors and can be prevented by using intravenous sodium chloride or isotonic sodium bicarbonate. N-acetylcysteine is no longer recommended, and patients at high risk should have metformin withheld until their renal function is normal.

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  • Question 48 - A 25-year-old woman comes to her General Practitioner complaining of urinary frequency, dysuria,...

    Incorrect

    • A 25-year-old woman comes to her General Practitioner complaining of urinary frequency, dysuria, suprapubic pain and back pain. The symptoms have been getting worse over the past 48 hours. During examination, she is febrile and tachycardic. She has no history of urinary infections.
      What is the most suitable investigation to arrange for this patient next?
      Choose ONE option only.

      Your Answer:

      Correct Answer: Urinary microscopy and culture

      Explanation:

      The most appropriate investigation to arrange for a patient presenting with symptoms suggestive of a urinary tract infection or pyelonephritis is urinary microscopy and culture. It is important to obtain a sample before starting empirical antibiotics to guide subsequent antibiotic choice if the initial course is ineffective. While genital swabs may be useful if there is a history of sexually transmitted infection, they are not as important as urine culture in this situation. Cystoscopy and ultrasound scans of the abdomen may be useful in other situations, but are not urgently indicated in this case. Similarly, a CTKUB would not be useful in investigating the cause of the infection, which can be determined through urine culture.

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  • Question 49 - A 68-year-old woman visits her GP with a complaint of urine leakage when...

    Incorrect

    • A 68-year-old woman visits her GP with a complaint of urine leakage when she coughs, sneezes, or laughs. She has been experiencing this for the past year intermittently, but it has become more severe over the last two months. She has no dysuria or haematuria and is in good health with no abdominal symptoms. All three of her children were delivered vaginally. A urine dip and culture test came back negative. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Stress incontinence

      Explanation:

      The most probable cause of urinary incontinence while coughing is stress incontinence. This occurs when the bladder neck drops below the levator ani sling, which can happen when there is increased intra-abdominal pressure, such as when coughing, laughing, or sneezing. Stress incontinence is characterized by leakage of urine during these activities. Neurogenic bladder, on the other hand, typically presents with overflow incontinence or retention, which is not limited to increased intra-abdominal pressure. Detrusor instability is associated with urgency and increased urinary frequency. Urinary tract infections and pyelonephritis are characterized by increased frequency, dysuria, pyrexia, and loin pain. In this case, the negative urine dip makes infection an unlikely cause.

      Understanding Urinary Incontinence: Causes, Classification, and Management

      Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

      Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

      In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

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      • Renal Medicine/Urology
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  • Question 50 - A 32-year-old traveler, recently returned from Thailand, arrives at the Emergency Department complaining...

    Incorrect

    • A 32-year-old traveler, recently returned from Thailand, arrives at the Emergency Department complaining of gradual right scrotal pain, tenderness, and swelling that has been worsening for the past 6 days. The medical team suspects epididymo-orchitis. What is the recommended empirical treatment in case the causative organism is unknown?

      Your Answer:

      Correct Answer: Ceftriaxone 500mg intramuscularly single dose, plus oral doxycycline 100mg twice daily for 10-14 days

      Explanation:

      For a suspected case of epididymo-orchitis in a high-risk patient for sexually transmitted infections (STI), such as this young businessman returning from Thailand, the recommended empirical treatment is ceftriaxone 500mg intramuscularly single dose, plus oral doxycycline 100mg twice daily for 10-14 days. This is because the likely organisms involved are Chlamydia trachomatis and Neisseria gonorrhoeae. If the clinical scenario suggests gram-negative organisms, as in the case of an older man with low risk of STI, ciprofloxacin 500mg twice daily for 10-14 days can be used as empirical treatment. However, amoxicillin, metronidazole, and clarithromycin are not suitable antibiotics to cover the possible organisms and are not recommended in the guidelines.

      Epididymo-orchitis is a condition where the epididymis and/or testes become infected, leading to pain and swelling. It is commonly caused by infections spreading from the genital tract or bladder, with Chlamydia trachomatis and Neisseria gonorrhoeae being the usual culprits in sexually active younger adults, while E. coli is more commonly seen in older adults with a low-risk sexual history. Symptoms include unilateral testicular pain and swelling, with urethral discharge sometimes present. Testicular torsion, which can cause ischaemia of the testicle, is an important differential diagnosis and needs to be excluded urgently, especially in younger patients with severe pain and an acute onset.

      Investigations are guided by the patient’s age, with sexually transmitted infections being assessed in younger adults and a mid-stream urine (MSU) being sent for microscopy and culture in older adults with a low-risk sexual history. Management guidelines from the British Association for Sexual Health and HIV (BASHH) recommend ceftriaxone 500mg intramuscularly as a single dose, plus doxycycline 100mg orally twice daily for 10-14 days if the organism causing the infection is unknown. Further investigations are recommended after treatment to rule out any underlying structural abnormalities.

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      • Renal Medicine/Urology
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  • Question 51 - You are clerking a 26-year-old in the emergency department. He reports experiencing painful...

    Incorrect

    • You are clerking a 26-year-old in the emergency department. He reports experiencing painful prolonged erection of the penis for the third time. What could be the probable cause of his recurrent presentations?

      Your Answer:

      Correct Answer: Sickle cell disease

      Explanation:

      Recurrent priapism is a common occurrence in individuals with sickle cell disease, while alcohol and drug abuse may also lead to this condition. Balanitis, on the other hand, is an inflammation that affects the head of the penis and is not associated with priapism. Paraphimosis, however, can be caused by the inability to retract the foreskin.

      Sickle-cell anaemia is a genetic disorder that occurs when abnormal haemoglobin, known as HbS, is produced due to an autosomal recessive condition. This condition is more common in individuals of African descent, as the heterozygous condition provides some protection against malaria. About 10% of UK Afro-Caribbean’s are carriers of HbS, and they only experience symptoms if they are severely hypoxic. Homozygotes tend to develop symptoms between 4-6 months when the abnormal HbSS molecules replace fetal haemoglobin.

      The pathophysiology of sickle-cell anaemia involves the substitution of the polar amino acid glutamate with the non-polar valine in each of the two beta chains (codon 6) of haemoglobin. This substitution decreases the water solubility of deoxy-Hb, causing HbS molecules to polymerise and sickle RBCs in the deoxygenated state. HbAS patients sickle at p02 2.5 – 4 kPa, while HbSS patients sickle at p02 5 – 6 kPa. Sickle cells are fragile and haemolyse, blocking small blood vessels and causing infarction.

      The definitive diagnosis of sickle-cell anaemia is through haemoglobin electrophoresis.

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      • Renal Medicine/Urology
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  • Question 52 - A 56-year-old man presents to the Emergency Department with nausea and vomiting, with...

    Incorrect

    • A 56-year-old man presents to the Emergency Department with nausea and vomiting, with associated lethargy. He has mild asthma which is well controlled with a steroid inhaler but has no other medical history of note. He does not smoke but drinks up to 30 units of alcohol a week, mostly on the weekends.
      Observations are as follows: Temperature is 37.2 oC, blood pressure is 108/68 mmHg, heart rate is 92 bpm and regular.
      On examination, the patient appears to be clinically dehydrated, but there are no other abnormalities noted.
      Investigations reveal the following:
      Investigation Result Normal Values
      Haemoglobin (Hb) 145 g/l 135–175 g/l
      White cell count (WCC) 8.2 × 109/l 4.0–11.0 × 109/l
      Urea 9.2 mmol/l 2.5–6.5 mmol/l
      Creatinine (Cr) 178 µmol/l
      (bloods carried out one year
      previously showed a creatinine
      of 76) 50–120 µmol/l
      Potassium (K+) 4.9 mmol/l 3.5–5.0 mmol/l
      Sodium (Na+) 131 mmol/l 135–145 mmol/l
      Which of the following is most suggestive of acute kidney injury rather than chronic renal failure?

      Your Answer:

      Correct Answer: Oliguria

      Explanation:

      Understanding the Signs and Symptoms of Acute and Chronic Renal Failure

      Renal failure can be difficult to diagnose, especially when there are no previous urea and electrolyte levels available for comparison. However, there are certain signs and symptoms that can indicate whether the condition is acute or chronic.

      Acute renal failure may present with acute lethargy/fatigue, dehydration, shortness of breath, nausea and vomiting, oliguria, acute onset peripheral edema/edema of the face, confusion, seizures, and coma. On the other hand, chronic renal failure may manifest as anemia, pruritus, long-standing fatigue, weight loss, reduced appetite, and a history of underlying medical conditions such as diabetes or hypertension.

      Oliguria, or reduced urine output, is a hallmark of renal failure and can be an early sign of acute renal injury. Nocturia, or increased urination at night, is often found in patients with chronic kidney disease. Peripheral neuropathy is likely to be present in patients with chronic renal failure due to an underlying history of diabetes. Raised parathyroid hormone levels are more commonly found in chronic renal failure, secondary to low calcium levels associated with the condition. Small kidneys are also seen in chronic renal failure, as long-standing conditions affecting the kidney can cause atrophy and reduce function, leading to progressive renal failure. The kidneys are more likely to be of normal size in acute injury.

      In summary, understanding the signs and symptoms of acute and chronic renal failure can aid in the diagnosis and management of this condition.

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  • Question 53 - A 60-year-old man comes in with complaints of nocturia, hesitancy, and terminal dribbling....

    Incorrect

    • A 60-year-old man comes in with complaints of nocturia, hesitancy, and terminal dribbling. During prostate examination, a moderately enlarged prostate with no irregular features and a well-defined median sulcus is found. Blood tests reveal a PSA level of 1.3 ng/ml.

      What is the best course of action for management?

      Your Answer:

      Correct Answer: Alpha-1 antagonist

      Explanation:

      First-line treatment for benign prostatic hyperplasia involves the use of alpha-1 antagonists.

      Benign prostatic hyperplasia (BPH) is a common condition that affects older men, with around 50% of 50-year-old men showing evidence of BPH and 30% experiencing symptoms. The risk of BPH increases with age, with around 80% of 80-year-old men having evidence of the condition. BPH typically presents with lower urinary tract symptoms (LUTS), which can be categorised into voiding symptoms (obstructive) and storage symptoms (irritative). Complications of BPH can include urinary tract infections, retention, and obstructive uropathy.

      Assessment of BPH may involve dipstick urine tests, U&Es, and PSA tests. A urinary frequency-volume chart and the International Prostate Symptom Score (IPSS) can also be used to assess the severity of LUTS and their impact on quality of life. Management options for BPH include watchful waiting, alpha-1 antagonists, 5 alpha-reductase inhibitors, combination therapy, and surgery. Alpha-1 antagonists are considered first-line treatment for moderate-to-severe voiding symptoms, while 5 alpha-reductase inhibitors may be indicated for patients with significantly enlarged prostates and a high risk of progression. Combination therapy and antimuscarinic drugs may also be used in certain cases. Surgery, such as transurethral resection of the prostate (TURP), may be necessary in severe cases.

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  • Question 54 - A 55-year-old man requests a PSA test due to his father's recent prostate...

    Incorrect

    • A 55-year-old man requests a PSA test due to his father's recent prostate cancer diagnosis. You perform a digital rectal exam and inform him that his prostate feels normal. After further conversation, you agree to proceed with the test. What is the appropriate timing for PSA testing to ensure accurate results?

      Your Answer:

      Correct Answer: PSA testing can be done after abstaining from ejaculation or vigorous exercise for 48 hours

      Explanation:

      To ensure accurate results, NICE recommends avoiding PSA testing for at least the following periods: 6 weeks after a prostate biopsy, 4 weeks after a confirmed urinary infection, 1 week after a digital rectal examination, and 48 hours after vigorous exercise or ejaculation, as these factors may cause an increase in PSA levels.

      Prostate specific antigen (PSA) is an enzyme produced by both normal and cancerous prostate cells. It is commonly used as a marker for prostate cancer, but its effectiveness as a screening tool is still debated. The NHS Prostate Cancer Risk Management Programme (PCRMP) has released guidelines for handling requests for PSA testing in asymptomatic men. While a recent European trial showed a reduction in prostate cancer deaths, it also revealed a high risk of over-diagnosis and over-treatment. As a result, the National Screening Committee has decided not to introduce a screening programme, but rather allow men to make an informed decision. The PCRMP recommends age-adjusted upper limits for PSA levels, while NICE Clinical Knowledge Summaries suggest a lower threshold for referral. PSA levels can also be raised by factors such as benign prostatic hyperplasia, prostatitis, and urinary tract infections.

      The specificity and sensitivity of PSA testing are poor, with a significant number of men with elevated PSA levels not having prostate cancer, and some with normal PSA levels having the disease. Various methods are used to add meaning to PSA levels, including age-adjusted upper limits and monitoring changes in PSA levels over time. It is also debated whether digital rectal examination causes a rise in PSA levels. It is important to note that PSA testing should be postponed after certain events, such as ejaculation or instrumentation of the urinary tract.

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      • Renal Medicine/Urology
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  • Question 55 - What is true about calcium homeostasis? ...

    Incorrect

    • What is true about calcium homeostasis?

      Your Answer:

      Correct Answer: 98% of filtered Ca2+ is reabsorbed in the kidneys

      Explanation:

      Regulation of Calcium in the Body

      Calcium is an essential mineral that plays a crucial role in various physiological processes in the body. Here are some key points about the regulation of calcium in the body:

      Reabsorption in the Kidneys: The kidneys filter 250 mmol of calcium ions a day in the glomerular filtrate and reabsorb 245 mmol, leading to a net average loss in the urine of about 5 mmol/day. The quantity of calcium ions excreted in the urine per day is partially under the influence of the plasma parathyroid hormone (PTH) level.

      Free Calcium Ions in Serum: In serum, most calcium is bound to albumin, and less than 50% of calcium is in the ionized form. The biological effect of calcium is determined by the amount of ionized calcium, rather than the total calcium.

      Bone Regulation: Body calcium content is mainly regulated by bone. Intestinal absorption of calcium is the main regulator of calcium content. The active absorption of calcium from the intestine is regulated by calcitriol concentration in the blood.

      Calcitonin and Renal Calcium Excretion: When the concentration of calcium rises, the parafollicular cells of the thyroid gland increase their secretion of calcitonin into the blood. At the same time, the parathyroid glands reduce their rate of PTH secretion into the blood. The resulting high levels of calcitonin in the blood stimulate the skeleton to remove calcium from the blood plasma and deposit it as bone. The reduced levels of PTH inhibit removal of calcium from the skeleton and increase the loss of calcium in the urine.

      Hypercalcaemia in Sarcoidosis: Absorptive hypercalcaemia occurs from conditions that produce increased serum calcitriol levels, as occurs in sarcoidosis. Increased calcitriol production from activated pulmonary macrophages leads to increased intestinal absorption of calcium, leading to raised calcium levels.

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      • Renal Medicine/Urology
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  • Question 56 - A 52-year-old man presents to his General Practitioner with frank haematuria that has...

    Incorrect

    • A 52-year-old man presents to his General Practitioner with frank haematuria that has been present for the past four weeks. He does not have any dysuria or frequency. He is otherwise well and has not lost any weight. A urine dip is positive for blood but negative for glucose and infection.
      What would be the most appropriate next step in this patient’s management?

      Your Answer:

      Correct Answer: Two-week wait referral to urology

      Explanation:

      Appropriate Referrals and Investigations for Patients with Haematuria

      Haematuria, or blood in the urine, can be a sign of underlying bladder cancer. According to The National Institute for Health and Care Excellence guidelines, patients aged over 45 years with unexplained visible haematuria should be urgently referred for potential bladder cancer. Additionally, patients over 60 years with unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test should also be referred urgently.

      An ultrasound scan might be arranged by the secondary care team for investigation of the bleeding from the renal tract. However, arranging this as an initial investigation through primary care could delay diagnosis. A 2-week wait ‘cancer exclusion’ referral would be more appropriate.

      A cystoscopy might be arranged as part of the investigation, but this should be arranged via the hospital team after the patient has been referred via the 2-week-wait pathway. Arranging an outpatient cystoscopy as a first-line investigation would be inappropriate since it could lead to a delay in diagnosis.

      Starting oral antibiotics would not help the patient, as her urine dip is negative for infection. Antibiotics could be considered if she had presented with symptoms or signs of infection such as dysuria, frequency or burning on urination. Frank haematuria which presents without symptoms of infection may be suggestive of bladder cancer, therefore she needs to be referred for further investigation.

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      • Renal Medicine/Urology
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  • Question 57 - You are having a conversation with a patient who is 60 years old...

    Incorrect

    • You are having a conversation with a patient who is 60 years old and has a PSA level of 10.2 ng/ml. What would be the next course of action that the urologist is likely to suggest?

      Your Answer:

      Correct Answer: Multiparametric MRI

      Explanation:

      The first-line investigation for suspected prostate cancer has been replaced by multiparametric MRI, replacing TRUS biopsy. This change was made in the 2019 NICE guidelines for investigating suspected prostate cancer in secondary care.

      Investigation for Prostate Cancer

      Prostate cancer is a common type of cancer that affects men. The traditional investigation for suspected prostate cancer was a transrectal ultrasound-guided (TRUS) biopsy. However, recent guidelines from NICE have now recommended the increasing use of multiparametric MRI as a first-line investigation. This is because TRUS biopsy can lead to complications such as sepsis, pain, fever, haematuria, and rectal bleeding.

      Multiparametric MRI is now the first-line investigation for people with suspected clinically localised prostate cancer. The results of the MRI are reported using a 5-point Likert scale. If the Likert scale is 3 or higher, a multiparametric MRI-influenced prostate biopsy is offered. If the Likert scale is 1-2, then NICE recommends discussing with the patient the pros and cons of having a biopsy. This approach helps to reduce the risk of complications associated with TRUS biopsy and ensures that patients receive the most appropriate investigation for their condition.

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      • Renal Medicine/Urology
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  • Question 58 - A 60-year-old man with no significant medical history presents with a lump in...

    Incorrect

    • A 60-year-old man with no significant medical history presents with a lump in his right groin that he noticed while showering. The lump has been present for two weeks and disappears when he lies down. He does not experience any discomfort, and there are no other gastrointestinal symptoms. Upon examination, a small reducible swelling is observed in the right groin. What is the best course of action for management?

      Your Answer:

      Correct Answer: Routine referral for surgical repair

      Explanation:

      Patient has an asymptomatic inguinal hernia and surgical repair is recommended as conservative management may not be effective.

      Understanding Inguinal Hernias

      Inguinal hernias are the most common type of abdominal wall hernias, with 75% of cases falling under this category. They are more prevalent in men, with a 25% lifetime risk of developing one. The main feature of an inguinal hernia is a lump in the groin area, which is located superior and medial to the pubic tubercle. This lump disappears when pressure is applied or when the patient lies down. Discomfort and aching are common symptoms, which can worsen with activity, but severe pain is rare. Strangulation, a serious complication, is uncommon.

      The clinical management of inguinal hernias involves treating medically fit patients, even if they are asymptomatic. A hernia truss may be an option for patients who are not fit for surgery, but it has little role in other patients. Mesh repair is the preferred method of treatment, as it is associated with the lowest recurrence rate. Unilateral hernias are generally repaired with an open approach, while bilateral and recurrent hernias are repaired laparoscopically. Patients can return to non-manual work after 2-3 weeks following an open repair and after 1-2 weeks following laparoscopic repair, according to the Department for Work and Pensions.

      Complications of inguinal hernias include early bruising and wound infection, as well as late chronic pain and recurrence. While traditional textbooks describe the anatomical differences between indirect and direct hernias, this is not relevant to clinical management. Overall, understanding the features, management, and complications of inguinal hernias is crucial for proper diagnosis and treatment.

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      • Renal Medicine/Urology
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  • Question 59 - A 55-year-old man with hypertension controlled with lisinopril undergoes blood testing for fatigue....

    Incorrect

    • A 55-year-old man with hypertension controlled with lisinopril undergoes blood testing for fatigue. The results show an eGFR >90 ml/min/1.73 m2 (reference range >90 ml/min/1.73 m2) and normal U&Es, and urinalysis is normal. He had a previous USS of the renal tract two years ago which was reported as normal.
      Which class of CKD does he belong to?

      Your Answer:

      Correct Answer: No CKD

      Explanation:

      Understanding Chronic Kidney Disease Stages and GFR Categories

      Chronic kidney disease (CKD) is a condition characterized by a gradual loss of kidney function over time. To assess the severity of CKD, healthcare professionals use a staging system based on the glomerular filtration rate (GFR), which measures how well the kidneys are filtering waste from the blood.

      A GFR of >90 without other evidence of kidney disease indicates normal renal function. However, if the GFR falls below this level, the patient may be classified into one of the following stages:

      – CKD stage 2: GFR 60-89 ml/min/1.73 m2 (mildly decreased)
      – CKD stage 3a: GFR 45-59 ml/min/1.73 m2 (mildly to moderately decreased)
      – CKD stage 3b: GFR 30-44 ml/min/1.73 m2 (moderately to severely decreased)
      – CKD stage 4: GFR 15-29 ml/min/1.73 m2 (severely decreased)
      – CKD stage 5: GFR <15 ml/min/1.73 m2 (kidney failure) To further assess the risk of adverse outcomes, the 2008 NICE guideline on CKD recommends subdividing stage 3 into 3a and 3b and adding the suffix P to denote significant proteinuria at any stage. Significant proteinuria is defined as a urinary albumin:creatinine ratio (ACR) of 30 mg/mmol or higher. Understanding the GFR categories and CKD stages can help healthcare professionals diagnose and manage CKD, as well as educate patients on their kidney function and potential risks.

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  • Question 60 - Maria is a 56-year-old Greek woman who has recently undergone an NHS health...

    Incorrect

    • Maria is a 56-year-old Greek woman who has recently undergone an NHS health check and has contacted her GP for the results. The health check included a blood pressure check, routine blood test, and a urine dip. Her blood pressure is 125/78 mmHg, and her urine dip is negative. The blood test results are as follows:

      - Hb 124 g/L (Female: 115 - 160)
      - Platelets 300 * 109/L (150 - 400)
      - WBC 4.5 * 109/L (4.0 - 11.0)
      - Na+ 138 mmol/L (135 - 145)
      - K+ 5.0 mmol/L (3.5 - 5.0)
      - Urea 4.2 mmol/L (2.0 - 7.0)
      - Creatinine 82 µmol/L (55 - 120)
      - eGFR 63 mL/min/1.73 m²

      What is the correct stage of Chronic Kidney Disease (CKD) for this patient?

      Your Answer:

      Correct Answer: No CKD

      Explanation:

      Diagnosing stages 1 and 2 of CKD should only be done if there is accompanying evidence to support the eGFR.

      Understanding Chronic Kidney Disease: eGFR and Classification

      Chronic kidney disease (CKD) is a condition that affects the kidneys’ ability to filter waste products from the blood. Serum creatinine, a commonly used measure of kidney function, may not provide an accurate estimate due to differences in muscle mass. To address this, formulas such as the Modification of Diet in Renal Disease (MDRD) equation were developed to estimate the glomerular filtration rate (eGFR). The MDRD equation takes into account variables such as serum creatinine, age, gender, and ethnicity.

      It is important to note that certain factors may affect the accuracy of eGFR results, such as pregnancy, muscle mass, and recent consumption of red meat. CKD can be classified based on eGFR, with stage 1 indicating a GFR greater than 90 ml/min with some sign of kidney damage on other tests. Stage 2 indicates a GFR of 60-90 ml/min with some sign of kidney damage, while stage 3a and 3b indicate a moderate reduction in kidney function with GFR ranges of 45-59 ml/min and 30-44 ml/min, respectively. Stage 4 indicates a severe reduction in kidney function with a GFR range of 15-29 ml/min, while stage 5 indicates established kidney failure with a GFR less than 15 ml/min, which may require dialysis or a kidney transplant. It is important to note that if all kidney tests are normal, there is no CKD.

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      • Renal Medicine/Urology
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  • Question 61 - A 72-year-old man is admitted after a fall and a period of time...

    Incorrect

    • A 72-year-old man is admitted after a fall and a period of time on the floor. He has a long history of chronic illness and immobility, with medications for hypertension, cardiac failure and chronic chest disease.
      On examination, he is obese, with a blood pressure of 110/75 mmHg, a pulse of 100 beats per minute and a temperature of 38.5°C. Respiratory examination reveals evidence of right lower lobe consolidation. He has no signs of traumatic bone injury.
      Investigations reveal the following:
      Investigation Result Normal value
      Chest X-ray Right lower lobe pneumonia
      Haemoglobin (Hb) 131 g/l 135–175 g/l
      White cell count (WCC) 15.4 × 109/l 4.0–11.0 × 109/l
      Platelets (PLT) 312 × 109/l 150–400 × 109/l
      Sodium (Na+) 142 mmol/l 135–145 mmol/l
      Potassium (K+) 6.7 mmol/l 3.5–5.0 mmol/l
      Urea 15.1 mmol/l 2.5–6.5 mmol/l
      Creatinine (Cr) 312 μmol/l 50–120 µmol/l
      Creatine kinase (CK) 1524 IU/l 23–175 IU/l
      Catheter specimen of urine: Red/brown in colour.
      +++ for blood.
      No red cells on microscopy
      Which of the following diagnoses fits best with this clinical picture?

      Your Answer:

      Correct Answer: Rhabdomyolysis

      Explanation:

      The patient’s elevated CK levels and urine test indicating blood without cells strongly suggest rhabdomyolysis as the cause of their kidney failure, likely due to their fall and prolonged time on the floor. Treatment should focus on managing hyperkalemia and ensuring proper hydration. While acute myocardial infarction cannot be ruled out entirely, the absence of discolored urine and other symptoms make rhabdomyolysis a more likely diagnosis. Acute tubular necrosis is also unlikely, as there are no epithelial cells present on urinalysis. While sepsis should be considered, the presence of red-colored urine and a history of a fall make rhabdomyolysis the most probable cause. Polymyositis, a type of inflammatory myopathy, typically presents with proximal myopathy and is more commonly seen in middle-aged women.

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  • Question 62 - A 65-year-old man visits his GP for a routine check-up. He has a...

    Incorrect

    • A 65-year-old man visits his GP for a routine check-up. He has a history of hypertension and is currently taking ramipril 5mg, amlodipine 10mg, and indapamide 2.5mg. Despite good adherence to his medications, his blood pressure has been consistently elevated during his previous appointments. Upon conducting ambulatory blood pressure monitoring, his average blood pressure is found to be 152/78 mmHg. His recent blood test results are as follows:
      - Na+ 134 mmol/L (135 - 145)
      - K+ 4.9 mmol/L (3.5 - 5.0)
      - Bicarbonate 24 mmol/L (22 - 29)
      - Urea 6 mmol/L (2.0 - 7.0)
      - Creatinine 125 µmol/L (55 - 120)

      What would be the most suitable course of action to manage his hypertension?

      Your Answer:

      Correct Answer: Add doxazosin

      Explanation:

      If a patient has poorly controlled hypertension despite being on an ACE inhibitor, CCB, and thiazide diuretic, adding an alpha- or beta-blocker is recommended by NICE if their potassium levels are above 4.5mmol/l. It is important to assess the patient for postural hypotension and discuss adherence with them. Seeking specialist advice is also advised. Fludrocortisone is not appropriate for treating hypertension and may increase blood pressure. Spironolactone would be the next step if potassium levels were below 4.5mmol/l. Indapamide cannot be increased any further if the patient is already on the maximum dose. It is important to treat hypertension promptly, especially if it has been confirmed through ABPM on multiple occasions.

      NICE Guidelines for Managing Hypertension

      Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of a calcium channel blocker or thiazide-like diuretic in addition to an ACE inhibitor or angiotensin receptor blocker.

      The guidelines also provide a flow chart for the diagnosis and management of hypertension. Lifestyle advice, such as reducing salt intake, caffeine intake, and alcohol consumption, as well as exercising more and losing weight, should not be forgotten and is frequently tested in exams. Treatment options depend on the patient’s age, ethnicity, and other factors, and may involve a combination of drugs.

      NICE recommends treating stage 1 hypertension in patients under 80 years old if they have target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For patients with stage 2 hypertension, drug treatment should be offered regardless of age. The guidelines also provide step-by-step treatment options, including adding a third or fourth drug if necessary.

      New drugs, such as direct renin inhibitors like Aliskiren, may have a role in patients who are intolerant of more established antihypertensive drugs. However, trials have only investigated the fall in blood pressure and no mortality data is available yet. Patients who fail to respond to step 4 measures should be referred to a specialist. The guidelines also provide blood pressure targets for different age groups.

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  • Question 63 - A 35-year-old man presents with haematuria and severe left flank pain. He is...

    Incorrect

    • A 35-year-old man presents with haematuria and severe left flank pain. He is agitated and unable to find a position that relieves the pain. On examination, his abdomen is soft with tenderness over the left lumbar region. He has no fever.
      What is the likely diagnosis?

      Your Answer:

      Correct Answer: Renal calculi

      Explanation:

      Common Renal Conditions: Symptoms and Characteristics

      Renal tract calculi, autosomal dominant polycystic kidney disease (ADPKD), acute pyelonephritis, renal cell carcinoma (RCC), and acute glomerulonephritis (GN) are common renal conditions that can cause various symptoms and have distinct characteristics.

      Renal Calculi: Sudden onset of severe pain in the flank, nausea, vomiting, and costovertebral angle tenderness.

      ADPKD: Pain in the abdomen, flank or back, hypertension, and palpable, bilateral flank masses.

      Acute Pyelonephritis: Fever, costovertebral angle pain, nausea, vomiting, and gross haematuria.

      RCC: Usually mild flank pain, haematuria, palpable flank mass, and hypercalcaemia manifestations.

      Acute GN: Sudden onset of haematuria, proteinuria, red blood cell casts in the urine, hypertension, and oedema.

      Timely diagnosis and management are crucial for these conditions to prevent further complications and improve patient outcomes.

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      • Renal Medicine/Urology
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  • Question 64 - A 5-year-old boy presents to the emergency department with generalised facial swelling. He...

    Incorrect

    • A 5-year-old boy presents to the emergency department with generalised facial swelling. He recently recovered from viral pharyngitis. He is otherwise healthy and meeting developmental milestones.

      Upon examination, he is alert and not experiencing any respiratory distress. There is pitting edema in his face and legs.

      Urinalysis reveals 4+ protein and no hematuria. Blood tests show a hemoglobin level of 180 g/L (normal range for males: 135-180, females: 115-160), platelets at 450 * 109/L (normal range: 150-400), WBC at 8.0 * 109/L (normal range: 4.0-11.0), bilirubin at 12 µmol/L (normal range: 3-17), ALP at 60 u/L (normal range: 30-100), ALT at 35 u/L (normal range: 3-40), γGT at 32 u/L (normal range: 8-60), and albumin at 10 g/L (normal range: 35-50).

      What is the recommended first-line treatment option for this likely diagnosis?

      Your Answer:

      Correct Answer: Prednisolone

      Explanation:

      The most appropriate treatment for minimal change glomerulonephritis, which is likely the cause of this patient’s facial edema, hypoalbuminemia, and proteinuria, is prednisolone. This medication is a corticosteroid and is considered the mainstay of therapy for this condition. Adrenaline, albumin infusion, and furosemide are not appropriate treatments for this patient’s condition. While albumin infusion may be used as adjunctive therapy, its effects will only be temporary. Adrenaline is used to treat anaphylaxis and would not be effective in treating minimal change disease. Furosemide may be used as adjunctive therapy, but its effects will also be temporary.

      Minimal change disease is a condition that typically presents as nephrotic syndrome, with children accounting for 75% of cases and adults accounting for 25%. While most cases are idiopathic, around 10-20% have a known cause, such as certain drugs, Hodgkin’s lymphoma, thymoma, or infectious mononucleosis. The pathophysiology of the disease involves T-cell and cytokine-mediated damage to the glomerular basement membrane, resulting in polyanion loss and reduced electrostatic charge, which increases glomerular permeability to serum albumin. The disease is characterized by nephrotic syndrome, normotension (hypertension is rare), and highly selective proteinuria, with only intermediate-sized proteins such as albumin and transferrin leaking through the glomerulus. Renal biopsy shows normal glomeruli on light microscopy, but electron microscopy reveals fusion of podocytes and effacement of foot processes.

      Management of minimal change disease typically involves oral corticosteroids, which are effective in 80% of cases. For steroid-resistant cases, cyclophosphamide is the next step. The prognosis for the disease is generally good, although relapse is common. Approximately one-third of patients have just one episode, one-third have infrequent relapses, and one-third have frequent relapses that stop before adulthood.

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      • Renal Medicine/Urology
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  • Question 65 - A 4-year-old girl is brought to the clinic with a history of fever...

    Incorrect

    • A 4-year-old girl is brought to the clinic with a history of fever with chills, vomiting, abdominal discomfort and loose stools for the past three days. Urine examination reveals the presence of white blood cells.
      What is a notable characteristic of urinary tract infections (UTIs) in young children?

      Your Answer:

      Correct Answer: Diarrhoea can be a presenting feature

      Explanation:

      Understanding Urinary Tract Infections in Children

      Urinary tract infections (UTIs) are common in children and can present with a variety of symptoms. In older children, diarrhoea with or without mucus may be a presenting symptom, especially with E. coli infection. While amoxicillin is a commonly used antibiotic, current guidelines recommend trimethoprim or nitrofurantoin for lower UTIs and co-amoxiclav for upper UTIs.

      Anatomical abnormalities of the urinary tract increase a child’s susceptibility to UTIs, but they are not present in the majority of cases. Imaging studies are not necessary for infants and children with a first episode of cystitis or a first febrile UTI who respond well to treatment and have a normal voiding pattern. Ultrasonography is the preferred imaging study for children with UTIs.

      Escherichia coli is the most common organism isolated in paediatric UTIs, but other organisms such as fungi and viruses can also cause infection. Poor containment of infection is more common in infants younger than 2 months, and UTIs can spread to the kidneys and bloodstream if left untreated.

      Understanding the symptoms and treatment options for UTIs in children is important for prompt diagnosis and management.

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      • Renal Medicine/Urology
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  • Question 66 - A 25-year-old female presents with a history of recurrent urinary tract infections over...

    Incorrect

    • A 25-year-old female presents with a history of recurrent urinary tract infections over the past year. An abdominal ultrasound is performed and the results indicate normal size kidneys and no abnormalities in the urinary tract. The liver, spleen, and pancreas are also normal. The right ovary and uterus appear normal, but a 4 cm simple ovarian cyst is noted on the left ovary. What would be the most appropriate course of action?

      Your Answer:

      Correct Answer: Repeat ultrasound in 12 weeks

      Explanation:

      Consider referral if the cyst remains after 12 weeks.

      Ovarian enlargement is typically diagnosed through ultrasound imaging, which can determine whether the cyst is simple or complex. Simple cysts are unilocular and more likely to be benign, while complex cysts are multilocular and more likely to be malignant. Management of ovarian enlargement depends on the patient’s age and symptoms. Younger women may be treated conservatively if the cyst is small and simple, with a repeat ultrasound scheduled in 8-12 weeks. Postmenopausal women, however, should always be referred to a gynecologist for assessment, as physiological cysts are unlikely in this population. It’s important to note that ovarian cancer can present with vague symptoms, leading to delayed diagnosis.

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  • Question 67 - A 50-year-old woman with type 1 diabetes mellitus is seen in the diabetes...

    Incorrect

    • A 50-year-old woman with type 1 diabetes mellitus is seen in the diabetes clinic. Her blood tests from three months ago showed:
      K+ 4.5 mmol/l
      Creatinine 116 µmol/l
      eGFR 47 ml/min
      She was started on lisinopril to manage hypertension and protect her kidneys. The medication was titrated up to the treatment dose. Her current blood results are:
      K+ 4.9 mmol/l
      Creatinine 123 µmol/l
      eGFR 44 ml/min
      What is the most appropriate action to take in this situation?

      Your Answer:

      Correct Answer: No action

      Explanation:

      The slight alterations in creatinine and eGFR are within acceptable limits and do not warrant discontinuation of ACE inhibitors.

      Hypertension Management in Chronic Kidney Disease

      Chronic kidney disease (CKD) patients often require more than two drugs to manage hypertension. The first-line treatment is ACE inhibitors, which are particularly effective in proteinuric renal disease such as diabetic nephropathy. However, these drugs may cause a small decrease in glomerular filtration pressure (GFR) and a rise in creatinine. According to NICE guidelines, a decrease in eGFR of up to 25% or a rise in creatinine of up to 30% is acceptable, but any increase should prompt careful monitoring and exclusion of other causes such as NSAIDs. A rise greater than this may indicate underlying renovascular disease.

      Furosemide is a useful antihypertensive drug in CKD patients, especially when the GFR falls below 45 ml/min. It also helps to lower serum potassium levels. However, high doses are usually required, and if the patient becomes dehydrated due to conditions such as gastroenteritis, the drug should be temporarily stopped. The NKF K/DOQI guidelines suggest a lower cut-off of less than 30 ml/min. Overall, hypertension management in CKD patients requires careful monitoring and individualized treatment plans.

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  • Question 68 - A 29-year-old man presents with a complaint of swelling in his left testicle....

    Incorrect

    • A 29-year-old man presents with a complaint of swelling in his left testicle. He denies any pain or urinary symptoms and is in good health. On examination, you note that the left testicle is significantly larger than the right testicle. There is no pain or tenderness on palpation. The patient denies any recent testicular trauma. What is the most appropriate next step in management?

      Your Answer:

      Correct Answer: 2 week wait referral for suspected testicular cancer

      Explanation:

      According to the 2015 NICE recommendation, suspicion of testicular cancer should arise if there is a painless increase in size or alteration in shape or texture of the testis. Referring to the emergency department is not a suitable route for referral, and all other choices would result in a delay in identifying a potentially severe condition.

      Understanding Testicular Cancer

      Testicular cancer is a type of cancer that commonly affects men between the ages of 20 and 30. Germ-cell tumors are the most common type of testicular cancer, accounting for around 95% of cases. These tumors can be divided into seminomas and non-seminomas, which include embryonal, yolk sac, teratoma, and choriocarcinoma. Other types of testicular cancer include Leydig cell tumors and sarcomas. Risk factors for testicular cancer include infertility, cryptorchidism, family history, Klinefelter’s syndrome, and mumps orchitis.

      The most common symptom of testicular cancer is a painless lump, although some men may experience pain. Other symptoms may include hydrocele and gynaecomastia, which occurs due to an increased oestrogen:androgen ratio. Tumor markers such as hCG, AFP, and beta-hCG may be elevated in germ cell tumors. Ultrasound is the first-line diagnostic tool for testicular cancer.

      Treatment for testicular cancer depends on the type and stage of the tumor. Orchidectomy, chemotherapy, and radiotherapy may be used. Prognosis for testicular cancer is generally excellent, with a 5-year survival rate of around 95% for seminomas and 85% for teratomas if caught at Stage I. It is important for men to perform regular self-examinations and seek medical attention if they notice any changes or abnormalities in their testicles.

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  • Question 69 - A 65-year-old woman with a history of early-onset Alzheimer's disease, difficult-to-manage hypertension, and...

    Incorrect

    • A 65-year-old woman with a history of early-onset Alzheimer's disease, difficult-to-manage hypertension, and incontinence presents to you with a complaint of increased urinary incontinence when coughing or sneezing after starting a new medication. Which of the following medications is the most likely culprit?

      Your Answer:

      Correct Answer: Doxazosin

      Explanation:

      Relaxation of the bladder outlet and urethra caused by doxazosin can exacerbate stress incontinence symptoms. This medication, classified as an alpha blocker, is commonly prescribed for hypertension and benign prostatic hyperplasia-related urinary retention. Therefore, doxazosin is the appropriate response.

      Understanding Urinary Incontinence: Causes, Classification, and Management

      Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

      Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

      In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

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  • Question 70 - A 7-year-old girl is diagnosed with nephrotic syndrome and a presumptive diagnosis of...

    Incorrect

    • A 7-year-old girl is diagnosed with nephrotic syndrome and a presumptive diagnosis of minimal change glomerulonephritis is made. What would be the most suitable course of treatment?

      Your Answer:

      Correct Answer: Prednisolone

      Explanation:

      A renal biopsy should only be considered if the response to steroids is inadequate.

      Minimal change disease is a condition that typically presents as nephrotic syndrome, with children accounting for 75% of cases and adults accounting for 25%. While most cases are idiopathic, around 10-20% have a known cause, such as certain drugs, Hodgkin’s lymphoma, thymoma, or infectious mononucleosis. The pathophysiology of the disease involves T-cell and cytokine-mediated damage to the glomerular basement membrane, resulting in polyanion loss and reduced electrostatic charge, which increases glomerular permeability to serum albumin. The disease is characterized by nephrotic syndrome, normotension (hypertension is rare), and highly selective proteinuria, with only intermediate-sized proteins such as albumin and transferrin leaking through the glomerulus. Renal biopsy shows normal glomeruli on light microscopy, but electron microscopy reveals fusion of podocytes and effacement of foot processes.

      Management of minimal change disease typically involves oral corticosteroids, which are effective in 80% of cases. For steroid-resistant cases, cyclophosphamide is the next step. The prognosis for the disease is generally good, although relapse is common. Approximately one-third of patients have just one episode, one-third have infrequent relapses, and one-third have frequent relapses that stop before adulthood.

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      • Renal Medicine/Urology
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  • Question 71 - A 50-year-old man with end-stage renal failure is scheduled for a renal transplant...

    Incorrect

    • A 50-year-old man with end-stage renal failure is scheduled for a renal transplant and is concerned about the potential increased risk of cancer. Can you provide information on which type of cancer he may be most susceptible to after the transplant?

      Your Answer:

      Correct Answer: Squamous cell carcinoma of the skin

      Explanation:

      After receiving a transplant, a significant number of patients develop cancer within 20 years. This is caused by the medication given to prevent rejection, which suppresses the immune system. Kidney transplant recipients are at a higher risk of developing skin cancer, particularly squamous cell carcinoma, as well as lymphoma and cervical cancer.

      Immunosuppression in Renal Transplant: Medications and Monitoring

      Renal transplant patients require immunosuppressive medications to prevent rejection of the transplanted kidney. The initial regime usually includes ciclosporin or tacrolimus with a monoclonal antibody. The maintenance regime involves the same medications with mycophenolate mofetil or sirolimus. Steroids may be added if the patient experiences more than one steroid-responsive acute rejection episode.

      Ciclosporin inhibits calcineurin, a phosphatase involved in T cell activation. Tacrolimus has a lower incidence of acute rejection compared to ciclosporin and causes less hypertension and hyperlipidaemia. However, it has a high incidence of impaired glucose tolerance and diabetes. Mycophenolate mofetil blocks purine synthesis by inhibiting IMPDH, which inhibits the proliferation of B and T cells. Sirolimus blocks T cell proliferation by blocking the IL-2 receptor, but it can cause hyperlipidaemia. Monoclonal antibodies, such as daclizumab and basiliximab, are selective inhibitors of the IL-2 receptor.

      Patients on long-term immunosuppression require regular monitoring for complications such as cardiovascular disease, renal failure, and malignancy. Tacrolimus and ciclosporin can cause hypertension, hyperglycaemia, and hyperlipidaemia, which can accelerate cardiovascular disease. Nephrotoxic effects of these medications, graft rejection, or recurrence of the original disease can cause renal failure. Patients should also be educated about minimizing sun exposure to reduce the risk of squamous cell carcinomas and basal cell carcinomas. Regular monitoring can help detect and manage these complications.

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  • Question 72 - A 27-year-old woman comes to her General Practitioner complaining of urinary frequency, dysuria,...

    Incorrect

    • A 27-year-old woman comes to her General Practitioner complaining of urinary frequency, dysuria, suprapubic pain and back pain. Her symptoms have been getting worse over the past 48 hours. On examination, she has a normal temperature, blood pressure and heart rate. A urine dipstick test shows positive results for leukocytes and nitrites but negative for blood. She is typically healthy and not taking any medications. This is her first time experiencing symptoms of a urinary tract infection. What would be the most appropriate initial investigation to arrange for this patient? Choose the SINGLE most likely option.

      Your Answer:

      Correct Answer: Urinary microscopy and culture

      Explanation:

      Appropriate Investigations for Suspected Urinary Tract Infection

      When a patient presents with symptoms suggestive of a urinary tract infection or pyelonephritis, the most appropriate investigation to arrange is urinary microscopy and culture. It is important to obtain a sample before starting empirical antibiotics, as this can guide subsequent antibiotic choice if the patient does not respond to the initial course. Recurrent episodes may require further investigation or referral to secondary care. Blood tests may be useful if the patient is unwell or has evidence of sepsis. However, a computed tomography of the kidneys, ureters, and bladder (CTKUB) would not be useful in this situation. Cystoscopy may be indicated for recurrent infections or unexplained bleeding, but not for a first episode. An urgent ultrasound of the renal tract may be useful to look for obstruction or anatomical abnormalities, but is not necessary for treatment. Inflammatory markers can be helpful, but urinary microscopy and culture are more appropriate in this situation.

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  • Question 73 - A 55-year-old woman presents to urogynaecology with symptoms of urge incontinence. Despite attempting...

    Incorrect

    • A 55-year-old woman presents to urogynaecology with symptoms of urge incontinence. Despite attempting bladder retraining, her symptoms persist. The decision is made to prescribe a muscarinic antagonist. Can you identify an example of a medication that falls under this category?

      Your Answer:

      Correct Answer: Tolterodine

      Explanation:

      Oxybutynin and solifenacin are other examples of muscarinic antagonists used for urinary incontinence. Muscarinic antagonists used for different conditions include ipratropium for chronic obstructive pulmonary disease and procyclidine for Parkinson’s disease.

      Understanding Urinary Incontinence: Causes, Classification, and Management

      Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

      Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

      In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

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      • Renal Medicine/Urology
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  • Question 74 - A 36-year-old woman attends surgery concerned that her 42-year-old brother has recently been...

    Incorrect

    • A 36-year-old woman attends surgery concerned that her 42-year-old brother has recently been diagnosed with adult polycystic kidney disease (PKD). She read online that it can run in families and is asking to be tested to ensure she does not have the condition.
      Which of the following tests is best to perform?

      Your Answer:

      Correct Answer: Ultrasonography of the renal tract

      Explanation:

      Diagnostic Tests for Autosomal Dominant Polycystic Kidney Disease (ADPKD)

      Autosomal Dominant Polycystic Kidney Disease (ADPKD) is a genetic disorder that affects the kidneys. There are several diagnostic tests available to detect ADPKD, including ultrasonography, full blood count (FBC) and urea and electrolytes (U&Es), PKD1 and 2 gene test, and urinalysis.

      Ultrasonography is the preferred test for ADPKD as it can detect cysts from 1 to 1.5 cm without the use of radiation or contrast material. The sensitivity of ultrasonography for ADPKD1 is 99% for at-risk patients older than 20 years. The diagnostic criteria for ADPKD1 were established by Ravine et al. in 1994 and depend on the number of cysts present in each kidney and the age of the patient.

      FBC and U&Es are performed to check for any abnormalities in blood count and electrolyte levels. An increased haematocrit in the FBC may result from increased erythropoietin secretion from cysts.

      PKD1 and 2 gene test is recommended for young adults with negative ultrasonographic findings who are being considered as potential kidney donors. Genetic testing by means of DNA linkage analysis has an accuracy of >95% for ADPKD1 and ADPKD2.

      Urinalysis and urine culture are also performed to check for any abnormalities in the urine. Microalbuminuria occurs in 35% of patients with ADPKD, but nephrotic-range proteinuria is uncommon.

      Referral to a geneticist is not necessary at this stage, as initial tests such as ultrasonography can be requested by the general practitioner (GP) in the community. However, patients with ADPKD may benefit from genetic counselling to provide them with more information about their genetic condition and assistance in understanding any options that may be available. This may be with a genetic counsellor, a clinical geneticist or a specialist genetic nurse.

      In conclusion, a combination of these diagnostic tests can help in the early detection and management of ADPKD.

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  • Question 75 - A 72-year-old man is brought in by ambulance after being found on the...

    Incorrect

    • A 72-year-old man is brought in by ambulance after being found on the floor early in the morning. He states that he tripped and fell in the evening and could not get up or get help. The following U&Es were taken:

      Na+ 135 mmol/l
      K+ 5.7 mmol/l
      Creatinine 347 mmol/l
      Urea 9.8 mmol/l
      Creatine kinase 14,550 I/U

      What could be the possible reason for this clinical presentation?

      Your Answer:

      Correct Answer: Rhabdomyolysis

      Explanation:

      If someone is stuck on the ground for an extended period after falling, they may develop rhabdomyolysis. This condition occurs when myoglobin, a toxic substance released from muscle tissue, damages the kidneys and causes acute kidney injury. Elevated levels of creatinine kinase and potassium are common indicators of rhabdomyolysis.

      Rhabdomyolysis is a condition that may be presented in an exam scenario where a patient has experienced a fall or prolonged epileptic seizure and is discovered to have an acute kidney injury upon admission. The condition is characterized by a disproportionately elevated creatinine level, elevated creatine kinase (CK), myoglobinuria, hypocalcaemia (as myoglobin binds calcium), elevated phosphate (released from myocytes), hyperkalaemia (which may develop before renal failure), and metabolic acidosis. The causes of rhabdomyolysis include seizure, collapse or coma (such as an elderly patient collapsing at home and being found eight hours later), ecstasy use, crush injury, McArdle’s syndrome, and certain drugs, such as statins (especially if co-prescribed with clarithromycin).

      The management of rhabdomyolysis involves administering intravenous fluids to maintain good urine output, and urinary alkalinization may be used in some cases. It is important to recognize the signs and symptoms of rhabdomyolysis early on to prevent further complications and ensure prompt treatment.

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  • Question 76 - You are seeing a 65-year-old patient in the outpatient clinic who complains of...

    Incorrect

    • You are seeing a 65-year-old patient in the outpatient clinic who complains of weight loss and a painless, growing penile sore that has been present for more than two months. The patient has a history of genital warts. What tests would be suitable for this probable diagnosis?

      Your Answer:

      Correct Answer: Immunoassay for Human Immunodeficiency Virus

      Explanation:

      Penile cancer is strongly linked to sexually transmitted diseases, including HIV infection. Therefore, it would be advisable to conduct an HIV test in cases where penile cancer is suspected. Liver function tests may not be as relevant as an HIV test since penile cancer is unlikely to spread to the liver. Instead, it can spread locally to lymph nodes, bones, and even the brain. Herpes is not a likely cause of penile cancer as it typically causes painful lesions that disappear within a week. Chancroid, caused by Haemophilus ducreyi, can cause painful lesions, while syphilis, caused by Treponema pallidum, can cause a painless ulcer known as a chancre. However, a chancre would not cause weight loss, and the lesion typically resolves within six to eight weeks, even without treatment.

      Understanding Penile Cancer: Causes, Symptoms, and Treatment

      Penile cancer is a rare type of cancer that is typically characterized by squamous cell carcinoma. It is a condition that affects the penis and can cause a variety of symptoms, including penile lump and ulceration. There are several risk factors associated with penile cancer, including human immunodeficiency virus infection, human papillomavirus virus infection, genital warts, poor hygiene, phimosis, paraphimosis, balanitis, and age over 50.

      When it comes to treating penile cancer, there are several options available, including radiotherapy, chemotherapy, and surgery. The prognosis for penile cancer can vary depending on the stage of the cancer and the treatment options chosen. However, the overall survival rate for penile cancer is approximately 50% at 5 years.

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      • Renal Medicine/Urology
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  • Question 77 - A 60-year-old woman has blood tests done by her primary care physician during...

    Incorrect

    • A 60-year-old woman has blood tests done by her primary care physician during a routine check-up. The results show a decline in her renal function. Upon further examination, she reports experiencing ankle swelling and increased fatigue. The renal team suspects she may have amyloidosis. What diagnostic test could be used to confirm this diagnosis?

      Your Answer:

      Correct Answer: Renal biopsy

      Explanation:

      Diagnostic Methods for Renal Amyloidosis

      Renal amyloidosis is a condition that can be challenging to diagnose. It is caused by the accumulation of proteinaceous material in tissues, which can be identified through a biopsy. Congo-red staining extracellular fibrillar material is a characteristic feature of amyloid protein in the kidney. While a urine dip may show proteinuria, a renal biopsy is necessary for a definitive diagnosis as proteinuria can be caused by other conditions. A bone marrow biopsy can confirm amyloidosis if there is suspicion of bone marrow infiltration. CT scans of the abdomen may reveal abnormalities in the kidneys or lymph nodes, but a renal biopsy is still required for a definitive diagnosis. As amyloidosis can affect other organs, a lung biopsy may not be the most targeted approach for diagnosing renal amyloidosis. Overall, a renal biopsy is the most reliable method for diagnosing renal amyloidosis.

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  • Question 78 - A 65-year-old woman with diabetes undergoes routine blood work and evaluation. Her estimated...

    Incorrect

    • A 65-year-old woman with diabetes undergoes routine blood work and evaluation. Her estimated glomerular filtration rate (eGFR) is reported as 52 ml/min/1.73 m2 (reference range >90 ml/min/1.73 m2). How would you classify her kidney function?

      Your Answer:

      Correct Answer: CKD stage 3a

      Explanation:

      Understanding Chronic Kidney Disease Stages

      Chronic kidney disease (CKD) is a condition where the kidneys gradually lose their function over time. To help diagnose and manage CKD, doctors use a staging system based on the glomerular filtration rate (GFR), which measures how well the kidneys are filtering waste from the blood.

      There are five stages of CKD, each with a different GFR range and level of kidney function.

      – Stage 1: GFR >90 ml/min/1.73 m2 (normal or high)
      – Stage 2: GFR 60–89 ml/min/1.73 m2 (mildly decreased)
      – Stage 3a: GFR 45–59 ml/min/1.73 m2 (mildly to moderately decreased)
      – Stage 3b: GFR 30–44 ml/min/1.73 m2 (moderately to severely decreased)
      – Stage 4: GFR 15–29 ml/min/1.73 m2 (severely decreased)
      – Stage 5: GFR <15 ml/min/1.73 m2 (kidney failure) The 2008 NICE guideline on CKD recommends subdividing stage 3 into 3a and 3b, and adding the suffix ‘P’ to denote significant proteinuria at any stage. Significant proteinuria is defined as a urinary albumin : creatinine ratio (ACR) of 30 mg/mmol or higher. Understanding the stage of CKD can help doctors determine the appropriate treatment and management plan for their patients. It’s important for individuals with CKD to work closely with their healthcare team to monitor their kidney function and manage any related health issues.

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  • Question 79 - A 55-year-old woman presents to her General Practitioner with headaches and is found...

    Incorrect

    • A 55-year-old woman presents to her General Practitioner with headaches and is found to have a blood pressure of 170/90 mmHg. She is a non-smoker and has a history of diabetes. Renal artery stenosis is suspected as the underlying cause of her condition.
      Which of the following tests is the gold-standard investigation for diagnosis of this condition?

      Your Answer:

      Correct Answer: Intra-arterial renal arteriography

      Explanation:

      Diagnostic Tests for Renal Artery Stenosis

      Renal artery stenosis is a condition that can lead to reduced blood flow to the kidneys. There are several diagnostic tests that can be used to assess for this condition.

      Intra-arterial renal arteriography is an invasive test that involves passing radio-opaque dye through the renal arteries to assess for normal flow or stenosis. This is considered the gold-standard test for diagnosing renal artery stenosis. It can also be used as a therapeutic modality if stents can be used to increase the lumen of the artery.

      Renal ultrasound scan can be used to assess for a shrunken appearance of the affected kidney and reduced vascular flow in the renal artery. Duplex ultrasound can augment this scan.

      Peripheral plasma renin activity is no longer considered suitable for initial testing for renovascular disease. Investigations demonstrating the presence of stenosis or occlusion of the renal artery are preferred.

      Magnetic resonance imaging (MRI) arteriography can be performed to assess for patent renal arteries or stenosis. However, a plain MRI without contrast would not be as effective as an intra-arterial examination.

      A 24-hour urinary protein test may be arranged to assess for other causes of reduced renal function, but it would not be useful in assessing for patent renal arteries.

      Overall, a combination of these tests may be used to diagnose renal artery stenosis and determine the best course of treatment.

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  • Question 80 - A 68-year-old woman visits her general practice for a routine check-up. She has...

    Incorrect

    • A 68-year-old woman visits her general practice for a routine check-up. She has a history of hypertension and occasional headaches. During screening tests, her serum creatinine level is found to be elevated at 190 μmol/l (reference range 53–106 μmol/l) and her haemoglobin level is low at 110 g/l (reference range 120–155 g/l). An X-ray of her chest shows a mass in her lung, and there is a monoclonal band on serum protein electrophoresis.
      What is the most likely cause of her impaired renal function?

      Your Answer:

      Correct Answer: Amyloidosis

      Explanation:

      Common Renal Disorders: Amyloidosis, Metformin Toxicity, Diabetic Nephropathy, Membranous Glomerulonephritis, and Urinary Tract Infection

      Renal disorders can present with a variety of symptoms and can be caused by various factors. Here are five common renal disorders and their characteristics:

      1. Amyloidosis: This disorder is caused by the deposition of abnormal amyloid fibrils that alter the normal function of tissues. Nearly 90% of the deposits consist of amyloid fibrils that are formed by the aggregation of misfolded proteins. In light chain amyloidosis (AL), the precursor protein is a clonal immunoglobulin light chain or light chain fragment. Treatment usually mirrors the management of multiple myeloma.

      2. Metformin Toxicity: Metformin is a widely used antidiabetic agent that holds the risk of developing a potentially lethal acidosis. Its accumulation is feasible in renal failure and acute overdosage. Toxic accumulation of the drug requires time after the development of renal failure, due to high clearance of metformin.

      3. Diabetic Nephropathy: This clinical syndrome is characterised by persistent albuminuria, progressive decline in the glomerular filtration rate, and elevated arterial blood pressure. Despite it being the most common cause of incident chronic renal failure, one should be wary about diagnosing diabetic nephropathy in the absence of proliferative retinopathy and proteinuria.

      4. Membranous Glomerulonephritis: This is one of the more common forms of nephrotic syndrome in adults. Some patients may present with asymptomatic proteinuria, but the major presenting complaint is oedema. Proteinuria is usually >3.5 g/24 h.

      5. Urinary Tract Infection (UTI): Causes of UTIs in men include prostatitis, epididymitis, orchitis, pyelonephritis, cystitis, urethritis, and urinary catheters. Dysuria is the most frequent complaint in men, and the combination of dysuria, urinary frequency, and urinary urgency is about 75% predictive for UTI.

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      • Renal Medicine/Urology
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  • Question 81 - A 48-year-old type 2 diabetic man has an annual review; bloods show creatinine...

    Incorrect

    • A 48-year-old type 2 diabetic man has an annual review; bloods show creatinine 109 μmol/l (reference range 53–106 μmol/l) and estimated glomerular filtration rate (eGFR) 64 (reference range >90 ml/min/1.73 m2). Urinary albumin : creatinine ratio (ACR) test = 37 mg/mmol (reference range <3 mg/mmol- 30 mg/mmol). The results are repeated 4 weeks later and the results are very similar.
      Which class of chronic kidney disease (CKD) does this fit?
      Select the SINGLE most appropriate class from the list below.
      Select ONE option only.

      Your Answer:

      Correct Answer: CKD stage 2

      Explanation:

      Understanding the Stages of Chronic Kidney Disease

      Chronic kidney disease (CKD) is a condition in which the kidneys gradually lose function over time. To help diagnose and manage CKD, healthcare professionals use a staging system based on the glomerular filtration rate (GFR), which measures how well the kidneys are filtering waste from the blood.

      The stages of CKD are as follows:

      – Stage 1: GFR >90 ml/min/1.73 m2 (normal or high)
      – Stage 2: GFR 60–89 ml/min/1.73 m2 (mildly decreased)
      – Stage 3a: GFR 45–59 ml/min/1.73 m2 (mildly to moderately decreased)
      – Stage 3b: GFR 30–44 ml/min/1.73 m2 (moderately to severely decreased)
      – Stage 4: GFR 15–29 ml/min/1.73 m2 (severely decreased)
      – Stage 5: GFR <15 ml/min/1.73 m2 (kidney failure) The 2008 National Institute for Health and Care Excellence (NICE) guideline on CKD recommends subdividing stage 3 into 3a and 3b, and adding the suffix P to denote significant proteinuria at any stage. Significant proteinuria is defined as a urinary albumin-to-creatinine ratio (ACR) of 30 mg/mmol or higher. Understanding the stage of CKD can help healthcare professionals determine appropriate treatment and management strategies to slow the progression of the disease and prevent complications.

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      • Renal Medicine/Urology
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  • Question 82 - A 47-year-old man presents with recurrent, intense pain in his right flank area....

    Incorrect

    • A 47-year-old man presents with recurrent, intense pain in his right flank area. A urine dipstick reveals the presence of blood and a CT KUB confirms the presence of a 7mm stone in the right ureter. The patient is administered intramuscular diclofenac to alleviate the pain. What other type of medication could potentially be helpful in this situation?

      Your Answer:

      Correct Answer: Alpha-adrenergic blocker

      Explanation:

      Calcium channel blockers may be utilized to assist in the natural passage of the stone.

      The management of renal stones involves initial medication and investigations, including an NSAID for analgesia and a non-contrast CT KUB for imaging. Stones less than 5mm may pass spontaneously, but more intensive treatment is needed for ureteric obstruction or renal abnormalities. Treatment options include shockwave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy. Prevention strategies include high fluid intake, low animal protein and salt diet, and medication such as thiazides diuretics for hypercalciuria and allopurinol for uric acid stones.

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      • Renal Medicine/Urology
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  • Question 83 - A 68-year-old man with chronic kidney disease (CKD) stage 3a with proteinuria has...

    Incorrect

    • A 68-year-old man with chronic kidney disease (CKD) stage 3a with proteinuria has hypertension which is not controlled with amlodipine.
      Which of the following other agents should be added?

      Your Answer:

      Correct Answer: Ramipril

      Explanation:

      Hypertension Medications: Guidelines and Recommendations

      Current guidelines recommend the use of renin-angiotensin system antagonists, such as ACE inhibitors (e.g. ramipril), ARBs (e.g. candesartan), and direct renin inhibitors (e.g. aliskiren), for patients with CKD and hypertension. β-blockers (e.g. bisoprolol) are not preferred as initial therapy, but may be considered in certain cases. Loop diuretics (e.g. furosemide) should only be used for clinically significant fluid overload, while thiazide-like diuretics (e.g. indapamide) can be offered as second line treatment. Low-dose spironolactone may be considered for further diuretic therapy, but caution should be taken in patients with reduced eGFR due to increased risk of hyperkalaemia.

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      • Renal Medicine/Urology
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  • Question 84 - A 45-year-old woman presents with macroscopic haematuria, proteinuria of 2.0 g/24 h (reference...

    Incorrect

    • A 45-year-old woman presents with macroscopic haematuria, proteinuria of 2.0 g/24 h (reference range <0.2 g/24 h) and a serum creatinine level of 167 µmol/l (reference range 50–110 µmol/l). What potential diagnosis should be considered?

      Your Answer:

      Correct Answer: IgA nephropathy

      Explanation:

      Common Causes of Glomerular Disease: Clinical Features and Characteristics

      Glomerular diseases are a group of conditions that affect the tiny filters in the kidneys responsible for removing waste and excess fluids from the blood. Here are some of the most common causes of glomerular disease, along with their clinical features and characteristics:

      1. IgA Nephropathy: This is the most common cause of glomerulonephritis worldwide. It is characterized by IgA deposition in the glomerular mesangium and can range from asymptomatic haematuria to rapidly progressive glomerulonephritis. It is often associated with persistent microscopic haematuria or recurrent macroscopic haematuria.

      2. Henoch-Schönlein Purpura: This is an acute IgA-mediated disorder that involves generalised vasculitis. It affects the small vessels of the skin, gastrointestinal tract, kidneys, joints, and rarely lungs and central nervous system. Haematuria, when present, is usually microscopic.

      3. Diabetic Nephropathy: This is a clinical syndrome characterized by persistent albuminuria, progressive decline in the glomerular filtration rate, and elevated arterial blood pressure. Macroscopic haematuria is uncommon and more suggestive of an alternative aetiology.

      4. Membranous Glomerulonephritis: This is one of the more common forms of nephrotic syndrome in adults. It causes asymptomatic proteinuria, but the major presenting complaint is oedema. Macroscopic haematuria is uncommon and more suggestive of an alternative aetiology.

      5. Focal Glomerulosclerosis: This is one of the most common causes of primary glomerular disease in adults. It causes asymptomatic proteinuria or nephrotic syndrome with or without renal insufficiency. The most common clinical presenting feature is nephrotic syndrome, characterized by generalised oedema, massive proteinuria, hypoalbuminaemia, and hyperlipidaemia.

      In summary, glomerular diseases can present with a range of clinical features and characteristics. Understanding these features can help clinicians diagnose and manage these conditions effectively.

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      • Renal Medicine/Urology
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  • Question 85 - A 26-year-old man undergoes a routine medical examination and is found to have...

    Incorrect

    • A 26-year-old man undergoes a routine medical examination and is found to have 3+ haematuria. This is confirmed on microscopy and on a second urinalysis 9 months later. He recalls experiencing two episodes of red urine in the past year, both of which occurred during upper respiratory tract infections. There is no family history of renal disease. He has no oedema but his blood pressure is 150/100 mmHg. His plasma creatinine level is 65 μmol/l (reference range 53–106 μmol/l). What is the most likely finding on a renal biopsy?

      Your Answer:

      Correct Answer: Immunoglobulin A (IgA) nephropathy

      Explanation:

      Common Kidney Diseases and Their Clinical Features

      Immunoglobulin A (IgA) Nephropathy, Kimmelstiel Wilson Lesions, Cast Nephropathy, Minimal Change Disease, and Thin Basement Membranes are some of the common kidney diseases that affect people. Each of these diseases has unique clinical features that help in their diagnosis.

      IgA Nephropathy, also known as Berger’s disease, is the most common cause of glomerulonephritis worldwide. It is characterized by predominant IgA deposition in the glomerular mesangium. Clinical features range from asymptomatic haematuria to rapidly progressive glomerulonephritis.

      Kimmelstiel–Wilson Lesions, also known as nodular glomerulosclerosis, is a complication of diabetes mellitus. It is characterized by the formation of nodules of hyaline material in regions of glomerular capillary loops in the glomerulus.

      Cast Nephropathy, also known as myeloma cast nephropathy, is the formation of urinary casts in the renal tubules from free immunoglobulin light chains, causing intratubular obstruction and damage, which leads to renal failure in the context of multiple myeloma.

      Minimal Change Disease, also known as lipoid nephrosis or nil disease, arises from a histopathologic lesion in the glomerulus and is characterized by intense proteinuria leading to oedema and intravascular volume depletion.

      Thin Basement Membranes is a group of inherited heterogeneous disorders involving the basement membranes of the kidney and frequently affecting the cochlea and eye as well. It is characterized by splitting and lamellation of the glomerular basement membrane.

      In conclusion, understanding the clinical features of these common kidney diseases is crucial in their diagnosis and management.

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  • Question 86 - A 42-year-old woman presents to you with a complaint of unintentional urine leakage...

    Incorrect

    • A 42-year-old woman presents to you with a complaint of unintentional urine leakage when she coughs for the past year. She denies any urgency to urinate. Despite trying various measures such as reducing caffeine intake, performing pelvic floor exercises, and achieving a BMI of 23 kg/m² from 29kg/m², she has only experienced minimal relief. She is hesitant to undergo surgery and is interested in exploring medication or other options. What medication is approved for treating stress incontinence?

      Your Answer:

      Correct Answer: Duloxetine

      Explanation:

      Stress incontinence is characterized by the involuntary release of urine during physical activity, coughing, or sneezing. Diagnosis is based on symptoms, and keeping a bladder diary can aid in evaluating the severity of the condition. Lifestyle changes, such as reducing caffeine intake, losing weight, and limiting fluid consumption, are recommended. Pelvic floor exercises should also be suggested. If symptoms persist despite these measures, surgery may be an option. If surgery is not feasible or desired, duloxetine, a serotonin-norepinephrine reuptake inhibitor (SNRI), may be prescribed. A ring pessary is not an effective treatment for stress incontinence, as it is used to address vaginal prolapse.

      Understanding Urinary Incontinence: Causes, Classification, and Management

      Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

      Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

      In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

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      • Renal Medicine/Urology
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  • Question 87 - A 67-year-old woman presents with vomiting and diarrhoea. Blood tests reveal an AKI...

    Incorrect

    • A 67-year-old woman presents with vomiting and diarrhoea. Blood tests reveal an AKI with the following results, which were normal during her last check-up with her GP 3 weeks ago. She is given intravenous fluids and a renal ultrasound scan is scheduled.
      Creatinine 180 umol/l
      Urea 10 mmol/l
      eGFR 25 ml/min
      Which medication should be discontinued until her renal function returns to normal?

      Your Answer:

      Correct Answer: Ramipril

      Explanation:

      This woman is experiencing an acute kidney injury, most likely caused by dehydration leading to pre-renal failure. The function of the kidneys is determined by the glomerulus’ ability to filter blood, which is dependent on the perfusion pressure of the glomerulus. This pressure is influenced by two factors: the overall blood flow to the kidney (which is reduced in cases of dehydration and hypovolemia) and the auto-regulation of the afferent and efferent arterioles, which fine-tunes the pressure.

      Prostaglandin E2 mediates the dilation of the afferent arteriole to increase blood flow, while angiotensin II mediates the constriction of the efferent arteriole to increase pressure. Non-steroidal anti-inflammatory drugs can disrupt this auto-regulation by blocking prostaglandin E2, contributing to acute kidney injury. However, oral aspirin is an exception and does not harm the kidneys. Drugs that block angiotensin II, such as ACE inhibitors like Ramipril and angiotensin receptor blockers, should be avoided during an AKI as they also disrupt auto-regulation.

      In contrast, ACE inhibitors and ARBs are beneficial in chronic kidney disease due to their antihypertensive and anti-inflammatory effects. In CKD, glomerular perfusion pressures are elevated, and reducing this pressure can help prevent glomerular damage and a decline in GFR.

      Angiotensin-converting enzyme (ACE) inhibitors are commonly used as the first-line treatment for hypertension and heart failure in younger patients. However, they may not be as effective in treating hypertensive Afro-Caribbean patients. These inhibitors are also used to treat diabetic nephropathy and for secondary prevention of ischaemic heart disease. The mechanism of action of ACE inhibitors is to inhibit the conversion of angiotensin I to angiotensin II. They are metabolized in the liver through phase 1 metabolism.

      ACE inhibitors may cause side effects such as cough, which occurs in around 15% of patients and may occur up to a year after starting treatment. This is thought to be due to increased bradykinin levels. Angioedema may also occur up to a year after starting treatment. Hyperkalaemia and first-dose hypotension are other potential side effects, especially in patients taking diuretics. ACE inhibitors should be avoided during pregnancy and breastfeeding, and caution should be exercised in patients with renovascular disease, aortic stenosis, or hereditary or idiopathic angioedema.

      Patients receiving high-dose diuretic therapy (more than 80 mg of furosemide a day) are at an increased risk of hypotension when taking ACE inhibitors. Before initiating treatment, urea and electrolytes should be checked, and after increasing the dose, a rise in creatinine and potassium may be expected. Acceptable changes include an increase in serum creatinine up to 30% from baseline and an increase in potassium up to 5.5 mmol/l. Patients with undiagnosed bilateral renal artery stenosis may experience significant renal impairment. The current NICE guidelines provide a flow chart for the management of hypertension.

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      • Renal Medicine/Urology
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  • Question 88 - A 58-year-old man has been treated for many years with amlodipine for hypertension....

    Incorrect

    • A 58-year-old man has been treated for many years with amlodipine for hypertension. Now this is not adequately controlling his blood pressure, and angiotensin-converting enzyme (ACE) inhibitor treatment is planned. On routine baseline blood tests, prior to commencing treatment, the estimated glomerular filtration rate (eGFR) is 49 ml/min/1.73 m2 (reference range >90 ml/min/1.73 m2).
      Which of the following is the most appropriate next step in his management?

      Your Answer:

      Correct Answer: Examine the patient, and perform urinalysis

      Explanation:

      Managing a Patient with Suspected Chronic Kidney Disease

      When a patient presents with suspected chronic kidney disease (CKD), it is important to perform a thorough examination and urinalysis to confirm the diagnosis. While patients with CKD stages 1-3 may not exhibit symptoms, those in stages 4-5 may experience endocrine/metabolic derangements or disturbances in water or electrolyte balance. Anaemia is often one of the first signs of CKD, but the lack of physical findings on examination does not exclude kidney disease. Initial screening for proteinuria can be done with a standard urine dipstick, and further testing may be necessary if the test is positive. Referral to a nephrology outpatient may be necessary, depending on the severity of the CKD. ACE inhibitors should only be started once the patient’s baseline renal function has been established, and blood tests should be rechecked in 2 weeks. Immediate admission is only necessary for patients with CKD stage 5 who present with acute indications for dialytic therapy.

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      • Renal Medicine/Urology
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  • Question 89 - A 25-year-old man presents with facial and ankle swelling that has been gradually...

    Incorrect

    • A 25-year-old man presents with facial and ankle swelling that has been gradually developing over the past week. He reports passing 'frothy' urine during the review of systems. A urine dipstick reveals protein +++ and a diagnosis of nephrotic syndrome is confirmed after a 24-hour urine sample. What is the probable cause of this presentation?

      Your Answer:

      Correct Answer: Minimal change disease

      Explanation:

      Minimal change disease is a condition that typically presents as nephrotic syndrome, with children accounting for 75% of cases and adults accounting for 25%. While most cases are idiopathic, around 10-20% have a known cause, such as certain drugs, Hodgkin’s lymphoma, thymoma, or infectious mononucleosis. The pathophysiology of the disease involves T-cell and cytokine-mediated damage to the glomerular basement membrane, resulting in polyanion loss and reduced electrostatic charge, which increases glomerular permeability to serum albumin. The disease is characterized by nephrotic syndrome, normotension (hypertension is rare), and highly selective proteinuria, with only intermediate-sized proteins such as albumin and transferrin leaking through the glomerulus. Renal biopsy shows normal glomeruli on light microscopy, but electron microscopy reveals fusion of podocytes and effacement of foot processes.

      Management of minimal change disease typically involves oral corticosteroids, which are effective in 80% of cases. For steroid-resistant cases, cyclophosphamide is the next step. The prognosis for the disease is generally good, although relapse is common. Approximately one-third of patients have just one episode, one-third have infrequent relapses, and one-third have frequent relapses that stop before adulthood.

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      • Renal Medicine/Urology
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  • Question 90 - A 65-year-old woman is discharged following an uncomplicated renal transplant for end-stage renal...

    Incorrect

    • A 65-year-old woman is discharged following an uncomplicated renal transplant for end-stage renal failure from hypertension. She received a kidney with 4 out of 6 mismatched human leukocyte antigen (HLA) and is taking the appropriate medications. Thirty days postoperatively, she developed watery loose stools, followed by a skin rash that is itchy, painful and red. On examination, she has a red-violet rash affecting her hands and feet.
      Investigations reveal the following:
      Investigation Result Normal value
      Haemoglobin (Hb) 131 g/l 115–155 g/l
      White cell count (WCC) 5.4 × 109/l 4.0–11.0 × 109/l
      Platelets (PLT) 280 ×109/l 150–400 × 109/l
      Sodium (Na+) 139 mmol/l 135–145 mmol/l
      Potassium (K+) 4.0 mmol/l 3.5–5.0 mmol/l
      Urea 15.1 mmol/l 2.5–6.5 mmol/l
      Creatinine (Cr) 170 μmol/l 50–120 µmol/l
      Alanine aminotransferase (ALT) 54 IU/l 7–55 IU/l
      Alkaline phosphatase (ALP) 165 IU/l 30–130 IU/l
      Bilirubin 62 µmol/l 2–17 µmol/l
      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Graft-versus-host disease

      Explanation:

      Differential Diagnosis for a Patient with Watery Diarrhea and Rash after Renal Transplantation

      Graft-versus-host disease (GVHD) is a potential complication of solid organ transplantation, with a mortality rate of 75%. It typically presents with watery diarrhea, a painful red-violet rash, and raised bilirubin. Diagnosis is obtained through biopsy, and treatment involves immunosuppressants such as tacrolimus and methylprednisolone.

      Acute viral hepatitis is another possible cause of diarrhea and jaundice, but the patient’s normal ALT and atypical symptoms make it unlikely. Azathioprine toxicity can cause bone marrow suppression, while Sjögren syndrome causes dry eyes and xerostomia, neither of which fit this patient’s presentation.

      Viral gastroenteritis is a consideration, but the presence of a painful/itchy rash and raised bilirubin suggests a need for further investigation. Given the recent renal transplant, a high degree of suspicion for GVHD and other potential complications is warranted.

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  • Question 91 - A 72-year-old man undergoes a new-patient screen by his general practitioner (GP) and...

    Incorrect

    • A 72-year-old man undergoes a new-patient screen by his general practitioner (GP) and is found to have microscopic haematuria. The GP also observes a raised erythrocyte sedimentation rate (ESR) and a calcium concentration of 3.1 mmol/l (reference range 2.2–2.7 mmol/l). During the examination, the patient is noted to have a varicocele. What is the most likely diagnosis based on these findings?

      Your Answer:

      Correct Answer: Renal-cell adenocarcinoma

      Explanation:

      Differential diagnosis of a renal mass in a 68-year-old man

      Renal-cell adenocarcinoma, retroperitoneal sarcoma, transitional-cell carcinoma, Wilms’ tumour and urinary tract infection (UTI) are among the possible causes of a renal mass in a 68-year-old man. Renal-cell adenocarcinoma is the most common type of kidney cancer in adults, but it may remain clinically silent for most of its course. Retroperitoneal sarcomas are rare tumours that usually present as an asymptomatic abdominal mass. Transitional-cell carcinoma is a malignant tumour arising from the transitional epithelial cells lining the urinary tract, and it often causes gross haematuria. Wilms’ tumour is a childhood malignancy that is not consistent with the age of the patient. UTIs in men are generally complicated and may cause dysuria, urinary frequency and urgency, but these symptoms are not elicited in this clinical scenario. Diagnosis and management of a renal mass require a thorough evaluation of the patient’s history, physical examination, laboratory tests, imaging studies and biopsy, if indicated. Treatment options depend on the type, stage and location of the tumour, as well as the patient’s overall health and preferences.

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      • Renal Medicine/Urology
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  • Question 92 - A 60-year-old woman visits her primary care physician complaining of loin pain and...

    Incorrect

    • A 60-year-old woman visits her primary care physician complaining of loin pain and blood in her urine. She has been experiencing fatigue lately and has lost around 4 kg of weight unintentionally in the past two weeks. She has a history of diabetes and her BMI is 30 kg/m2. You suspect that she may have renal cancer. What type of kidney tumour is most likely causing her symptoms?

      Your Answer:

      Correct Answer: Clear cell carcinoma

      Explanation:

      Types of Kidney Tumours and Their Characteristics

      Kidney tumours can present with symptoms such as haematuria, loin pain, fatigue, and weight loss. These symptoms should be considered as red flags for urgent referral for potential renal cancer. Renal cell carcinomas are the most common type of kidney tumours in adults, accounting for 80% of renal cancers. They are divided into clear cell (most common), papillary, chromophobe, and collecting duct carcinomas. Sarcomatoid renal cancers are rare and have a poorer prognosis compared to other types of renal cancer. Angiomyolipomas are benign kidney tumours commonly seen in patients with tuberous sclerosis. Transitional cell carcinomas account for 5-10% of adult kidney tumours and start in the renal pelvis. They are the most common type of cancer in the ureters, bladder, and urethra. Wilms’ tumour is the most common kidney cancer in children and is not likely to be found in adults.

      Understanding the Different Types of Kidney Tumours

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  • Question 93 - An 82-year-old man is admitted under the medical take with acute chest pain....

    Incorrect

    • An 82-year-old man is admitted under the medical take with acute chest pain. An MRI of the chest with contrast is requested. His blood tests show acute kidney injury (AKI).
      Which of the following would mitigate the risk of worsening AKI when using contrast?

      Your Answer:

      Correct Answer: IV fluids before and after a CT scan

      Explanation:

      Preventing Contrast-Induced Nephropathy: Strategies and Considerations

      Contrast-induced nephropathy (CIN) is a common complication of IV contrast administration, particularly in patients with pre-existing renal impairment. CIN is characterized by a decline in renal function within 48-72 hours of contrast exposure. To prevent CIN, strategies that focus on maintaining intravascular volume expansion are crucial.

      Intravenous (IV) saline 0.9% is preferred over 0.45% saline as it enhances intravascular volume expansion and prevents renin-angiotensin activation. Oral fluids are beneficial but not as effective as IV hydration. Volume expansion should begin 6 hours before the procedure and continue for 6-24 hours post-procedure, with post-procedure hydration being more important than pre-procedure hydration.

      Diuretics alone are not recommended, but a recent meta-analysis suggests that furosemide with matched hydration may reduce the incidence of CIN in high-risk patients. Fluid restriction is not recommended, and oral fluids should be encouraged.

      Dialysis is required in less than 1% of patients with CIN, with a slightly higher incidence in patients with underlying renal impairment and those undergoing primary percutaneous coronary intervention for myocardial infarction. N-Acetylcysteine (NAC) supplementation has been associated with a significant decrease in CIN risk and blood creatinine levels, but it does not reduce mortality or the need for dialysis.

      In conclusion, preventing CIN requires a multifaceted approach that includes maintaining intravascular volume expansion, avoiding fluid restriction, and considering NAC supplementation in high-risk patients.

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      • Renal Medicine/Urology
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  • Question 94 - A 32-year-old woman who is 8 weeks pregnant comes in with symptoms of...

    Incorrect

    • A 32-year-old woman who is 8 weeks pregnant comes in with symptoms of 'cystitis'. She reports experiencing dysuria, suprapubic pains, and frequency for the past two days. She denies any vaginal bleeding. Upon urine dipstick testing, leucocytes and nitrites are present. Her temperature is 37.6ºC. What is the best course of action for management?

      Your Answer:

      Correct Answer: Oral nitrofurantoin

      Explanation:

      This expectant woman displays indications that align with a urinary tract infection. According to the BNF, trimethoprim should not be used during the initial trimester as it can hinder folate. Ciprofloxacin is not recommended for use during pregnancy. Since the patient is clearly experiencing a UTI and has a fever, prompt treatment is necessary instead of waiting for the MSU.

      Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. The management of UTIs depends on various factors such as the patient’s age, gender, and pregnancy status. For non-pregnant women, local antibiotic guidelines should be followed if available. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. However, if the patient is aged over 65 years or has visible or non-visible haematuria, a urine culture should be sent. Pregnant women with UTIs should be treated with nitrofurantoin, amoxicillin, or cefalexin for seven days. Trimethoprim should be avoided during pregnancy as it is teratogenic in the first trimester. Asymptomatic bacteriuria in pregnant women should also be treated to prevent progression to acute pyelonephritis. Men with UTIs should be offered a seven-day course of trimethoprim or nitrofurantoin unless prostatitis is suspected. A urine culture should be sent before antibiotics are started. Catheterised patients should not be treated for asymptomatic bacteria, but if symptomatic, a seven-day course of antibiotics should be given. Acute pyelonephritis requires hospital admission and treatment with a broad-spectrum cephalosporin or quinolone for 10-14 days. Referral to urology is not routinely required for men who have had one uncomplicated lower UTI.

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  • Question 95 - A 47-year-old man undergoes evaluation for hypertension and is discovered to have blood...

    Incorrect

    • A 47-year-old man undergoes evaluation for hypertension and is discovered to have blood + on a urine dipstick from a recently voided sample. What could be the possible cause of this result?

      Your Answer:

      Correct Answer: Exercise

      Explanation:

      Managing Haematuria: Causes, Testing, and Referral Guidelines

      The management of haematuria can be challenging due to the lack of widely followed guidelines. Haematuria is classified as either visible or non-visible, with the latter being found in approximately 2.5% of the population. Transient or spurious non-visible haematuria can be caused by factors such as urinary tract infections, menstruation, vigorous exercise, or sexual intercourse. Persistent non-visible haematuria, on the other hand, may be indicative of underlying conditions such as cancer, stones, benign prostatic hyperplasia, prostatitis, urethritis, or renal causes like IgA nephropathy or thin basement membrane disease.

      Current evidence does not support routine screening for haematuria, but patients taking aspirin or warfarin should still be investigated. Urine dipstick is the preferred test for detecting haematuria, and persistent non-visible haematuria is defined as blood being present in 2 out of 3 samples tested 2-3 weeks apart. Renal function, albumin:creatinine (ACR) or protein:creatinine ratio (PCR), and blood pressure should also be checked. NICE urgent cancer referral guidelines recommend urgent referral for patients aged 45 years or older with unexplained visible haematuria or aged 60 years or older with unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test. Patients under 40 years of age with normal renal function, no proteinuria, and normotension may be managed in primary care.

      In conclusion, managing haematuria requires careful consideration of the underlying causes and appropriate testing. Referral guidelines can help guide healthcare professionals in determining which patients require urgent or non-urgent referral for further investigation.

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      • Renal Medicine/Urology
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  • Question 96 - Among the ethnic groups listed, which one has the highest likelihood of developing...

    Incorrect

    • Among the ethnic groups listed, which one has the highest likelihood of developing prostate cancer?

      Your Answer:

      Correct Answer: African-Caribbean

      Explanation:

      Prostate Cancer and Ethnicity: Understanding the Differences

      Prostate cancer is a disease that affects men of all ethnicities, but the prevalence and mortality rates vary significantly among different racial groups. African-Caribbean men have the highest incidence and mortality rates, while Chinese and Indian men tend to have lower rates. White men have an intermediate risk, with the highest rates in certain regions. However, the role of genetics versus environmental factors is still unclear, and access to healthcare and socioeconomic status may also play a role. Understanding these differences is crucial for improving prevention, diagnosis, and treatment of prostate cancer in all populations.

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      • Renal Medicine/Urology
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  • Question 97 - A 67-year-old male presents to an urgent care centre with concerns about decreased...

    Incorrect

    • A 67-year-old male presents to an urgent care centre with concerns about decreased frequency of urination. He reports only urinating once in the past 12 hours and feels unable to urinate despite the urge to do so. The patient has a medical history of diabetes mellitus managed with metformin and chronic back pain managed with ibuprofen and PPI cover. He has no known allergies. Blood tests reveal the following results: Na+ 139 mmol/L (135 - 145), K+ 4.8 mmol/L (3.5 - 5.0), Bicarbonate 22 mmol/L (22 - 29), Urea 7.1 mmol/L (2.0 - 7.0), and Creatinine 200 µmol/L (55 - 120). The patient's previous creatinine level was 119 µmol/L. The general practitioner refers the patient to the emergency department for further investigation. What is the correct classification?

      Your Answer:

      Correct Answer: Acute Kidney Injury stage 1

      Explanation:

      The patient in this vignette meets the criteria for AKI Stage 1, which is characterized by a moderate increase in serum creatinine (1.5-1.9 times the baseline) or reduced urine output (<0.5 mL/kg/hr) for at least 6 hours. The patient has risk factors such as age, diabetes mellitus, and NSAID use for back pain, which can contribute to AKI. It is important to note that AKI is a classification and not a diagnosis. AKI Stage 2 is characterized by a more significant increase in serum creatinine (2-2.9 times the baseline) or reduced urine output for at least 12 hours. The vignette does not show renal function that is severe enough to meet this classification. AKI Stage 3 is the most severe stage, with a serum creatinine increase of 3 times or more from baseline or reduced urine output for at least 24 hours. Again, the patient’s renal function is not severe enough to meet this classification. There is no AKI Stage 4 or 5. Chronic kidney disease is classified from stages 1-5 based on the patient’s estimated glomerular filtration rate (eGFR). A patient with CKD Stage 4 would have an eGFR of 15-29 ml/min/1.73m², while a patient with CKD Stage 5 would have end-stage renal disease with an eGFR <15 ml/min/1.73m² or be receiving renal replacement therapy. The NICE guidelines for acute kidney injury (AKI) identify risk factors such as emergency surgery, CKD, diabetes, and use of nephrotoxic drugs. Diagnostic criteria include a rise in creatinine, fall in urine output, or fall in eGFR. The KDIGO criteria are used to stage AKI, with stage 3 indicating the most severe cases. Referral to a nephrologist is recommended for certain cases, such as AKI with no known cause or inadequate response to treatment. Complications of AKI include CKD, hyperkalaemia, metabolic acidosis, and fluid overload.

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      • Renal Medicine/Urology
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  • Question 98 - A 32-year-old woman presents to the Emergency Department with right flank pain radiating...

    Incorrect

    • A 32-year-old woman presents to the Emergency Department with right flank pain radiating to her groin. A urine dipstick reveals the presence of blood. You suspect a possible ureteric stone.
      What is the most suitable imaging modality to confirm the diagnosis?

      Your Answer:

      Correct Answer: Non contrast abdominopelvic/kidney, ureters and bladder (KUB) computed tomography (CT)

      Explanation:

      Imaging Modalities for Nephrolithiasis Diagnosis

      Nephrolithiasis, or kidney stones, can be diagnosed through various imaging modalities. Non-contrast abdominopelvic computed tomography (CT) scans are the preferred imaging modality due to their high sensitivity and specificity. Contrast scans are not recommended for initial assessment as they can obscure calcific densities. CT scans can also reveal other pathologies. Seriated X-rays, specifically KUB X-rays, can be used in conjunction with CT scans for follow-up of stone patients. Intravenous urography, while widely available and inexpensive, is less sensitive than CT scans and requires IV contrast material and multiple delayed films. Magnetic resonance imaging (MRI) is not recommended for acute renal colic evaluation as it is more expensive and less effective in stone detection. Renal ultrasonography is mainly used in pregnancy or in combination with a KUB X-ray for determining hydronephrosis or ureteral dilatation associated with a urinary tract calculus, but is less accurate in diagnosing ureteral stones and not reliable for stones smaller than 5 mm.

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      • Renal Medicine/Urology
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  • Question 99 - A 65-year-old woman presents to her General Practitioner complaining of general malaise, lethargy...

    Incorrect

    • A 65-year-old woman presents to her General Practitioner complaining of general malaise, lethargy and ankle swelling. She was commenced on omeprazole eight weeks ago to treat indigestion. Urea, electrolytes and eGFR demonstrate that her renal function has declined significantly. She is referred to the renal team and a diagnosis of acute interstitial nephritis (AIN) is suspected.
      What would be the next most useful investigation in order to confirm the diagnosis in this patient?

      Your Answer:

      Correct Answer: Full blood count

      Explanation:

      Investigations for Acute Interstitial Nephritis

      Acute interstitial nephritis (AIN) can present with non-specific symptoms of acute kidney dysfunction, such as nausea, vomiting, and malaise. A decline in kidney function is typical, and a raised creatinine on U+ESs may already be present. A drug history, along with a raised eosinophilia on full blood count (FBC), can aid in the diagnosis of AIN. Common causes of AIN include drugs like proton-pump inhibitors, non-steroidal anti-inflammatories, and antibiotics, as well as autoimmune disorders or other systemic diseases.

      Antinuclear antibody (ANA) testing should be performed to rule out systemic lupus erythematosus (SLE), which can coexist with AIN. However, a positive ANA test alone would not confirm a diagnosis of AIN.

      Urinary dipstick testing for protein is not useful in diagnosing AIN, as patients with AIN typically do not have protein in their urine. Nephrotic syndrome can occur as a rare complication of AIN.

      Renal biopsy may be necessary to confirm the diagnosis of AIN, as it is characterized by an inflammatory infiltrate in the kidney interstitium. However, if the patient’s condition is drug-induced, a renal biopsy may not be required if a raised creatinine and eosinophil count, along with the drug history, are sufficient for diagnosis.

      Chest X-ray (CXR) may be necessary to investigate other potential causes of AIN, such as sarcoidosis. If sarcoidosis is suspected and the CXR is inconclusive, a computed tomography chest may be performed. However, if the patient has been exposed to a drug that predisposes them to AIN, a diagnosis of drug-induced interstitial nephritis is more likely than an underlying systemic disease.

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      • Renal Medicine/Urology
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  • Question 100 - A 6-year-old boy has been treated for a first urinary tract infection. There...

    Incorrect

    • A 6-year-old boy has been treated for a first urinary tract infection. There was no evidence of pyelonephritis. Urine culture demonstrated growth of Escherichia coli. He was given a course of trimethoprim and recovered well.
      Which of the following is the most appropriate next step in his management?
      Select the SINGLE most appropriate next step from the list below. Select ONE option only.

      Your Answer:

      Correct Answer: No imaging required

      Explanation:

      Imaging Guidelines for Urinary Tract Infections in Children

      Urinary tract infections (UTIs) are common in children and can be divided into upper and lower UTIs. Current guidelines recommend different imaging investigations based on the type of UTI and the child’s age. For infants and children aged ≥6 months with a first-time UTI that responds to treatment, routine ultrasonography is not recommended unless the child has an atypical UTI. Micturating cystourethrography (MCUG) is indicated if renal and bladder ultrasonography reveals hydronephrosis, scarring, or other findings that suggest high-grade vesicoureteral reflux (VUR) or obstructive uropathy. Ultrasonography of the urinary tract is the imaging study of choice in children with a UTI, and it is useful in excluding obstructive uropathy and identifying renal damage caused by pyelonephritis. Technectium-99m-labelled dimercaptosuccinic acid (99mTc-DMSA) is a scintigraphic agent that can be used to assess acute pyelonephritis, renal cortical scarring, and the identification of a malpositioned kidney. However, no imaging is required for a typical, non-recurrent UTI in a child aged ≥3 years. Atypical UTI features include being seriously ill, having poor urine flow, an abdominal or bladder mass, raised creatinine, septicaemia, failure to respond to treatment with suitable antibiotics within 48 hours, or infection with non-E. coli organisms.

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      • Renal Medicine/Urology
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  • Question 101 - A 50-year-old man visits his doctor for routine blood tests before starting a...

    Incorrect

    • A 50-year-old man visits his doctor for routine blood tests before starting a statin medication. During the tests, his renal function is discovered to be impaired, and he is referred for further evaluation.
      Na+ 135 mmol/l
      K+ 4.2 mmol/l
      Urea 15 mmol/l
      Creatinine 152 µmol/l
      What sign would suggest that the man's condition is chronic rather than acute?

      Your Answer:

      Correct Answer: Hypocalcaemia

      Explanation:

      Distinguishing between Acute Kidney Injury and Chronic Kidney Disease

      One of the most effective ways to differentiate between acute kidney injury (AKI) and chronic kidney disease (CKD) is through the use of renal ultrasound. In most cases, patients with CKD will have small kidneys that are bilateral. However, there are some exceptions to this rule, including individuals with autosomal dominant polycystic kidney disease, diabetic nephropathy in its early stages, amyloidosis, and HIV-associated nephropathy.

      In addition to renal ultrasound, there are other features that can suggest CKD rather than AKI. For example, individuals with CKD may experience hypocalcaemia due to a lack of vitamin D. By identifying these distinguishing factors, healthcare professionals can more accurately diagnose and treat patients with kidney disease. Proper diagnosis is crucial, as the treatment and management of AKI and CKD differ significantly.

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      • Renal Medicine/Urology
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  • Question 102 - A 55-year-old woman complains of urine leakage issues for the past six months....

    Incorrect

    • A 55-year-old woman complains of urine leakage issues for the past six months. She reports frequent urination and difficulty reaching the toilet in time. She denies experiencing urine loss during coughing or sneezing. What is the best initial treatment option?

      Your Answer:

      Correct Answer: Bladder retraining

      Explanation:

      The initial treatment for urinary incontinence differs depending on the type. For urge incontinence, bladder retraining is the recommended first-line approach. On the other hand, for stress incontinence, pelvic floor muscle training is the preferred initial treatment.

      Understanding Urinary Incontinence: Causes, Classification, and Management

      Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

      Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

      In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

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      • Renal Medicine/Urology
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  • Question 103 - Male infertility is most commonly associated with which of the following? ...

    Incorrect

    • Male infertility is most commonly associated with which of the following?

      Your Answer:

      Correct Answer: Varicocele

      Explanation:

      Male Reproductive Conditions: Varicocele, Spermatocele, BPH, Hydrocele, and Testicular Cancer

      Male infertility can be caused by deficiencies in sperm formation, concentration, or transportation. One common condition that can lead to infertility is varicocele, which is a dilatation of the veins in the scrotum. Although varicoceles are present in 15% of the male population, they are considered the most common correctable cause of infertility. Varicoceles may lead to impaired testicular function and can progress over time, but repair can improve semen parameters and fertility.

      Spermatocele, on the other hand, is a benign cystic accumulation of sperm that arises from the epididymis and is not associated with male infertility. Treatment is usually not recommended in men of reproductive age due to the risk of epididymal damage.

      Benign prostatic hyperplasia (BPH) is a histological diagnosis characterized by prostate enlargement, but it is not associated with male infertility. In patients with spinal cord injury, infertility may be related to functional failure of the prostate gland and hyperactivation of the immune system.

      Hydrocele is a fluid collection within the scrotum or along the spermatic cord, but it is not associated with male infertility. Testicular cancer, the most common solid malignant tumor in young men, is also not directly associated with infertility, but surgical resection may lead to retrograde ejaculation and other fertility issues.

      The initial evaluation of male infertility should be rapid, non-invasive, and cost-effective, as most conditions can be diagnosed with history, physical examination, and hormonal and semen analysis alone. Further studies can be ordered if necessary.

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      • Renal Medicine/Urology
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  • Question 104 - A 35-year-old man comes to the clinic complaining of pain and swelling in...

    Incorrect

    • A 35-year-old man comes to the clinic complaining of pain and swelling in his right testicle that has been gradually developing over the past two days. He rates the pain as 5/10 on the pain scale. Although he recently returned from a trip to Spain four weeks ago, he denies experiencing any dysuria or urethral discharge. Upon examination, the right testicle is tender and swollen. The patient's heart rate is 84/min and his temperature is 36.8ºC. Based on these symptoms, what is the most probable underlying diagnosis?

      Your Answer:

      Correct Answer: Epididymo-orchitis

      Explanation:

      The symptoms and pain caused by testicular torsion are usually more severe and acute, while a patient with mumps would experience prodromal symptoms and parotitis.

      Epididymo-orchitis is a condition where the epididymis and/or testes become infected, leading to pain and swelling. It is commonly caused by infections spreading from the genital tract or bladder, with Chlamydia trachomatis and Neisseria gonorrhoeae being the usual culprits in sexually active younger adults, while E. coli is more commonly seen in older adults with a low-risk sexual history. Symptoms include unilateral testicular pain and swelling, with urethral discharge sometimes present. Testicular torsion, which can cause ischaemia of the testicle, is an important differential diagnosis and needs to be excluded urgently, especially in younger patients with severe pain and an acute onset.

      Investigations are guided by the patient’s age, with sexually transmitted infections being assessed in younger adults and a mid-stream urine (MSU) being sent for microscopy and culture in older adults with a low-risk sexual history. Management guidelines from the British Association for Sexual Health and HIV (BASHH) recommend ceftriaxone 500mg intramuscularly as a single dose, plus doxycycline 100mg orally twice daily for 10-14 days if the organism causing the infection is unknown. Further investigations are recommended after treatment to rule out any underlying structural abnormalities.

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      • Renal Medicine/Urology
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  • Question 105 - A 29-year-old pregnant woman presents to the GP clinic for a review. She...

    Incorrect

    • A 29-year-old pregnant woman presents to the GP clinic for a review. She is currently 8 weeks pregnant and has undergone urine microscopy, culture, and sensitivity tests. Despite having no fever or dysuria, the following results were obtained:
      - Red blood cells < 106/L
      - White blood cells 100 x 106/L
      - Culture Escherichia coli > 106/L colonies
      - Sensitivity trimethoprim sensitive, cefalexin sensitive, nitrofurantoin resistant

      What would be the most appropriate course of action for management?

      Your Answer:

      Correct Answer: Cefalexin for 7 days

      Explanation:

      Pregnant women with asymptomatic bacteriuria should receive immediate antibiotic treatment. In this case, cefalexin for 7 days is the appropriate choice based on the sensitivity results of the culture. Amoxicillin is another option, but without sensitivity data, it cannot be recommended. Nitrofurantoin should be avoided as the bacteria are resistant, and a 5-day course is insufficient. No treatment is not an option for pregnant women as it increases the risk of pyelonephritis. Trimethoprim should also be avoided due to its potential impact on fetal development as a folate antagonist.

      Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. The management of UTIs depends on various factors such as the patient’s age, gender, and pregnancy status. For non-pregnant women, local antibiotic guidelines should be followed if available. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. However, if the patient is aged over 65 years or has visible or non-visible haematuria, a urine culture should be sent. Pregnant women with UTIs should be treated with nitrofurantoin, amoxicillin, or cefalexin for seven days. Trimethoprim should be avoided during pregnancy as it is terat