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Question 1
Correct
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A 42-year-old woman is diagnosed with chronic kidney disease and requires long-term haemodialysis. What is the most common long-term complication for patients receiving haemodialysis?
Your Answer: Ischaemic heart disease
Explanation:Cardiovascular Disease and Other Complications in End-Stage Renal Disease Patients
End-stage renal disease (ESRD) patients are at high risk for cardiovascular disease, which is the leading cause of death in this population. Atherosclerosis is present in all long-term dialysis patients, and premature cardiac death occurs at a much higher rate than in the general population. Hypertension is a major risk factor for cardiovascular disease and is often poorly controlled in ESRD patients.
In addition to cardiovascular disease, ESRD patients may also develop β2 microglobulin amyloidosis, which can cause physical handicaps and even life-threatening cervical spinal cord compression. This condition typically appears after 5 years or more of hemodialysis and can affect any joint, but is especially common in the sternoclavicular joint and hips. Clinical features include periarthritis of the shoulders, carpal tunnel syndrome, and spondyloarthropathy.
Kidney transplant recipients may also face complications, including an increased risk of non-Hodgkin’s lymphoma and skin cancers due to prolonged immunosuppressive therapy. However, there is no known increased risk of gastrointestinal malignancy in patients on long-term dialysis.
Overall, ESRD patients require careful monitoring and management to prevent and address these potential complications.
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This question is part of the following fields:
- Kidney And Urology
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Question 2
Correct
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What is the ethnic group with the highest incidence of prostate cancer?
Your Answer: Asian
Explanation:Factors to Consider in Prostate Cancer
Ethnicity is a significant factor to consider when discussing prostate cancer. The incidence of prostate cancer varies geographically, with the highest rates found in men of black ethnic group and the lowest rates in Chinese men. Age is another important factor, as prostate cancer is rare in men under 50 years old, with the majority of diagnoses made in patients over 65. Family history is also a risk factor, particularly in younger men. Prostate cancer can cluster within families, and having a first-degree relative under 70 with prostate cancer can double a patient’s relative risk of developing the disease. Finally, diet is another factor to consider, as a diet rich in red meat and dairy products has been linked to an increased risk of prostate cancer. By taking these factors into account, healthcare professionals can better assess a patient’s risk of developing prostate cancer and provide appropriate screening and treatment.
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This question is part of the following fields:
- Kidney And Urology
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Question 3
Correct
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A 75-year-old woman presents with complaints of dysuria and increased frequency of micturition. She has been experiencing these symptoms on and off for several months. Upon urinalysis, microscopic haematuria and 2-3 white cells per high power field are detected, but the urine culture is sterile. What is the most suitable treatment for her?
Your Answer: Topical oestrogen cream
Explanation:Atrophic Urethritis/Vaginitis in Postmenopausal Women: Symptoms and Treatment
Postmenopausal women often experience symptoms of atrophic urethritis/vaginitis due to dryness and atrophy of the urethral tissue. This condition can cause discomfort, pain during intercourse, and urinary incontinence. However, topical oestrogen cream can have a dramatic response in improving or curing these symptoms.
It is important to note that atrophic urethritis/vaginitis is not caused by an infection, so antibiotic therapy or alkalinisation of the urine will not be effective. Corticosteroids are also not helpful in treating this condition.
In addition to improving urinary incontinence, topical oestrogen may also reduce the risk of recurrent urinary tract infections in postmenopausal women. However, it is important to rule out other underlying pathology before using oestrogen for this indication.
Overall, atrophic urethritis/vaginitis is a common condition in postmenopausal women, but it can be effectively treated with topical oestrogen cream.
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This question is part of the following fields:
- Kidney And Urology
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Question 4
Correct
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You see a 30-year-old gentleman who is being investigated for subfertility. His semen analysis result shows a mild oligozoospermia.
What would be the next most appropriate management step?Your Answer: Repeat test in 12 weeks
Explanation:Repeat Confirmatory Semen Analysis and Other Fertility Advice
According to NICE, it is recommended to repeat confirmatory semen analysis after 3 months (12 weeks) from the initial test. This is to allow the cycle of spermatozoa to be completed. However, if there is a significant deficiency in spermatozoa, a repeat test should be taken as early as possible.
While it is known that elevated scrotal temperatures can reduce semen quality, it is uncertain whether wearing loose-fitting underwear can improve fertility. Nevertheless, it is still advisable to wear looser underwear while trying to conceive.
Screening for antisperm antibodies is not recommended as there is no effective treatment to improve fertility. The significance of these antibodies is still unclear.
Overall, these recommendations can help couples who are trying to conceive to take practical steps towards improving their fertility.
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This question is part of the following fields:
- Kidney And Urology
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Question 5
Correct
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A 16-year-old male comes to the clinic complaining of fever, low-grade back pain, and rigors that have been going on for 3 days. He also reports an increase in his frequency of urination. He has a medical history of well-controlled asthma and type 1 diabetes mellitus (T1DM).
What is the most common causative agent of this condition?Your Answer: Escherichia coli
Explanation:Pyelonephritis is most commonly caused by E. coli, with young females having the highest incidence. Given the patient’s symptoms and previous T1DM diagnosis, this is a likely diagnosis. While other organisms can also cause pyelonephritis, any that can ascend up the genitourinary tract, E. coli is the most frequent culprit.
Understanding Acute Pyelonephritis
Acute pyelonephritis is a condition that is commonly caused by an ascending infection, usually E. coli from the lower urinary tract. However, it can also be caused by the spread of infection through the bloodstream, leading to sepsis. The clinical features of acute pyelonephritis include fever, rigors, loin pain, nausea/vomiting, and symptoms of cystitis such as dysuria and urinary frequency.
To diagnose acute pyelonephritis, patients should have a mid-stream urine (MSU) test before starting antibiotics. For patients with signs of acute pyelonephritis, hospital admission should be considered. Local antibiotic guidelines should be followed if available, and the BNF currently recommends a broad-spectrum cephalosporin or a quinolone (for non-pregnant women) for 7-10 days.
In summary, acute pyelonephritis is a serious condition that requires prompt diagnosis and treatment. Patients should be aware of the symptoms and seek medical attention if they experience any of the clinical features mentioned above.
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This question is part of the following fields:
- Kidney And Urology
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Question 6
Correct
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You are consulting with a 28-year-old male who is experiencing difficulties with his erections. He is generally healthy, a non-smoker, and consumes 8-10 units of alcohol per week. He has been in a relationship for 3 years, and this issue is beginning to impact their intimacy.
After conducting a thorough psychosexual history, which findings from the following list would indicate an organic cause rather than a psychogenic cause for his issue?Your Answer: A normal libido
Explanation:Erectile dysfunction (ED) is a condition where a person is unable to achieve or maintain an erection that is sufficient for satisfactory sexual performance. The causes of ED can be categorized into organic, psychogenic, mixed, or drug-induced.
Symptoms that indicate a psychogenic cause of ED include a sudden onset of the condition, early loss of erection, self-stimulated or waking erections, premature ejaculation or inability to ejaculate, relationship problems, major life events, and psychological issues.
On the other hand, symptoms that suggest an organic cause of ED include a gradual onset of the condition, normal ejaculation, normal libido (except in hypogonadal men), risk factors in medical history such as cardiovascular, endocrine or neurological conditions, previous operations, radiotherapy, or trauma to the pelvis or scrotum, current use of drugs known to cause ED, smoking, high alcohol consumption, and use of recreational or bodybuilding drugs.
Therefore, having a normal libido is indicative of an organic cause of ED.
Erectile dysfunction (ED) is a condition where a man is unable to achieve or maintain an erection that is sufficient for sexual performance. It is not a disease but a symptom that can be caused by organic, psychogenic, or mixed factors. It is important to differentiate between the causes of ED, with factors such as a gradual onset of symptoms and lack of tumescence favoring an organic cause, while sudden onset of symptoms and decreased libido favoring a psychogenic cause. Risk factors for ED include cardiovascular disease, alcohol use, and certain medications.
To assess for ED, it is recommended to measure lipid and fasting glucose serum levels to calculate cardiovascular risk. Free testosterone should also be measured in the morning, and if low or borderline, further assessment may be needed. PDE-5 inhibitors, such as sildenafil, are the first-line treatment for ED and should be prescribed to all patients regardless of the cause. Vacuum erection devices can be used as an alternative for those who cannot or will not take PDE-5 inhibitors. Referral to urology may be appropriate for young men who have always had difficulty achieving an erection, and those who cycle for more than three hours per week should be advised to stop.
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This question is part of the following fields:
- Kidney And Urology
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Question 7
Correct
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What is an accurate epidemiological statement about prostate cancer?
Your Answer: Lifetime risk of a prostate cancer diagnosis in the UK is 1 in 250 men
Explanation:Prostate Cancer in England and Wales
Approximately 10,000 men die of prostate cancer each year in England and Wales, making it the second leading cause of cancer deaths in men after lung cancer. The lifetime risk of a prostate cancer diagnosis in the UK is 1 in 14 men. However, one of the difficulties with investigating and diagnosing prostate cancer in older men is that as we age, most men have detectable prostate cancer. But, three-quarters of them will grow older and die of something else, and the prostate cancer itself will not impact their life expectancy.
The five-year survival rate from prostate cancer in the UK is 81%, which is relatively high compared to other types of cancer. However, early detection and treatment are crucial for improving survival rates. Therefore, it is important for men to be aware of the symptoms of prostate cancer and to undergo regular screenings, especially if they are at higher risk due to factors such as age, family history, or ethnicity. By detecting prostate cancer early, men can receive timely treatment and improve their chances of survival.
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This question is part of the following fields:
- Kidney And Urology
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Question 8
Correct
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A 58-year-old woman with diet-controlled type II diabetes is being treated with a thiazide, a beta blocker and an angiotensin-converting enzyme (ACE) inhibitor for hypertension. Her General Practitioner has recently increased some of her medication and has asked her to return to the surgery for a repeat blood pressure measurement and blood test to check for renal function and electrolytes.
Investigations:
Investigation Results Normal value
Serum potassium concentration 3.1 mmol/l 3.5-5.0 mmol/l
Blood pressure 156/94 mmHg <140/90 mmHg
Serum creatinine concentration 115 µmol/l 70-120 µmol/l
Which of the following is the single most likely cause of her hypokalaemia?
Your Answer: The thiazide diuretic
Explanation:Causes of Hypokalaemia: Understanding the Factors that Lower Potassium Levels
Hypokalaemia, or low potassium levels, can be caused by various factors. One of the common causes is the use of thiazide diuretics, which inhibit sodium reabsorption in the distal convoluted tubule of the kidney. This can lead to excess potassium loss via urine, especially in patients with underlying renal impairment. However, the use of a potassium-sparing diuretic can help offset this problem.
Another possible cause of hypokalaemia is primary aldosteronism, also known as Conn syndrome. This condition can cause hypertension and hypokalaemia, but it only accounts for a small percentage of hypertension cases.
Low dietary potassium intake is also a factor that can contribute to hypokalaemia, although it is less common in people who are eating normally. Potassium depletion is more likely to occur in cases of starvation.
Renal tubular acidosis type 4, which is often seen in patients with diabetes, is associated with hyperkalaemia rather than hypokalaemia. On the other hand, renal tubular acidosis types 1 and 2 are linked to hypokalaemia.
Lastly, angiotensin-converting enzyme inhibitors tend to raise the plasma potassium concentration rather than decrease it, due to their action on the renin-angiotensin-aldosterone system.
Understanding the various causes of hypokalaemia is important in identifying and treating the underlying condition.
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This question is part of the following fields:
- Kidney And Urology
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Question 9
Correct
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A 54-year-old woman with Rheumatoid arthritis complains of dysuria, frequency, and foul-smelling urine for the past 3 days. Upon urinalysis, blood, nitrites, leukocytes, and protein are detected. Upon checking her repeat prescription, it is found that she is taking methotrexate for her Rheumatoid disease. She has no allergies. Which antibiotic should not be prescribed due to the potential for severe bone marrow suppression?
Your Answer: Trimethoprim
Explanation:The combination of methotrexate and antibiotics containing trimethoprim can lead to bone marrow suppression and potentially fatal pancytopenia. Therefore, it is important to avoid using trimethoprim and co-trimoxazole with methotrexate due to their anti-folate properties, which can cause folate depletion. Fatal cases of megaloblastic anemia and pancytopenia have been reported. Nitrofurantoin and cefalexin do not have any known interactions with methotrexate, and penicillins may reduce its excretion.
Methotrexate is an antimetabolite that hinders the activity of dihydrofolate reductase, an enzyme that is crucial for the synthesis of purines and pyrimidines. It is a significant drug that can effectively control diseases, but its side-effects can be life-threatening. Therefore, careful prescribing and close monitoring are essential. Methotrexate is commonly used to treat inflammatory arthritis, especially rheumatoid arthritis, psoriasis, and acute lymphoblastic leukaemia. However, it can cause adverse effects such as mucositis, myelosuppression, pneumonitis, pulmonary fibrosis, and liver fibrosis.
Women should avoid pregnancy for at least six months after stopping methotrexate treatment, and men using methotrexate should use effective contraception for at least six months after treatment. Prescribing methotrexate requires familiarity with guidelines relating to its use. It is taken weekly, and FBC, U&E, and LFTs need to be regularly monitored. Folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after methotrexate dose. The starting dose of methotrexate is 7.5 mg weekly, and only one strength of methotrexate tablet should be prescribed.
It is important to avoid prescribing trimethoprim or co-trimoxazole concurrently as it increases the risk of marrow aplasia. High-dose aspirin also increases the risk of methotrexate toxicity due to reduced excretion. In case of methotrexate toxicity, the treatment of choice is folinic acid. Overall, methotrexate is a potent drug that requires careful prescribing and monitoring to ensure its effectiveness and safety.
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This question is part of the following fields:
- Kidney And Urology
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Question 10
Correct
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Which statement about erectile dysfunction (ED) is correct?
Your Answer: Prolactin and LH levels should be measured
Explanation:Important Information about Erectile Dysfunction
Erectile dysfunction (ED) is a common condition that affects a significant portion of the population, with prevalence estimates ranging from 32 to 52%. It is important to measure both lipids and glucose in all patients, as early detection of ED may precede cardiovascular disease (CVD) symptoms by up to three years. While the causes of ED are multifactorial, it is recommended to only measure pituitary hormones if testosterone levels are low. Additionally, it is important to note that recreational drugs such as cocaine and heroin can also cause ED. Overall, it is crucial to be aware of the potential risk factors and causes of ED in order to properly diagnose and treat this condition.
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This question is part of the following fields:
- Kidney And Urology
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Question 11
Correct
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You have arranged a semen analysis for a 37-year-old man who has been trying to conceive with his wife for the last 12 months without success.
The results are as follows:
Semen volume 1.8 ml (1.5ml or more)
pH 7.4 (7.2 or more)
Sperm concentration 12 million per ml (15 million per ml or more)
Total sperm number 21 million (39 million or more)
Total motility 40% progressively motile (32% or more)
Vitality 68% live spermatozoa (58% or more)
Normal forms 5% (4% or more)
His partner is also currently undergoing investigations. You plan on referring him to fertility services.
What is the appropriate course of action based on these semen analysis results?Your Answer: Repeat test in 3 months
Explanation:If a semen sample shows abnormalities, it is recommended to schedule a repeat test after 3 months to allow for the completion of the spermatozoa formation cycle. In cases where there is a severe deficiency in spermatozoa (azoospermia or a sperm concentration of less than 5 million per ml), an immediate recheck may be necessary. Based on World Health Organisation criteria, this man has mild oligozoospermia/oligospermia with a sperm concentration of 10 to 15 million per ml, thus requiring a confirmatory test after 3 months.
Semen analysis is a test that requires a man to abstain from sexual activity for at least 3 days but no more than 5 days before providing a sample to the lab. It is important that the sample is delivered to the lab within 1 hour of collection. The results of the test are compared to normal values, which include a semen volume of more than 1.5 ml, a pH level of greater than 7.2, a sperm concentration of over 15 million per ml, a morphology of more than 4% normal forms, a motility of over 32% progressive motility, and a vitality of over 58% live spermatozoa. It is important to note that different reference ranges may exist, but these values are based on the NICE 2013 guidelines.
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This question is part of the following fields:
- Kidney And Urology
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Question 12
Correct
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A 55-year-old man with chronic renal failure presents with anaemia.
Select the single most likely cause.Your Answer: Erythropoietin deficiency
Explanation:Understanding Anaemia in Chronic Kidney Disease
Anaemia is a common complication in patients with chronic kidney disease, with a prevalence of about 12%. As the estimated glomerular filtration rate (eGFR) falls, the prevalence of anaemia increases. Patients should be investigated if their haemoglobin falls to 110g/L or less or if symptoms of anaemia develop.
The typical normochromic normocytic anaemia of chronic kidney disease mainly develops from decreased renal synthesis of erythropoietin. Anaemia becomes more severe as the glomerular filtration rate decreases. Iron deficiency is also common and may be due to poor dietary intake or occult bleeding. Other factors contributing to anaemia include the presence of uraemic inhibitors, a reduced half-life of circulating blood cells, or deficiency of folate or vitamin B12.
Although supplements of vitamin C have been used as adjuvant therapy in the anaemia of chronic kidney disease, NICE recommends that they should not be prescribed for this purpose as evidence suggests no benefit. It is important to monitor and manage anaemia in patients with chronic kidney disease to improve their quality of life and reduce the risk of complications.
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This question is part of the following fields:
- Kidney And Urology
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Question 13
Correct
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You assess a 78-year-old woman who has a history of type 2 diabetes and mild cognitive impairment. During a previous visit, you referred her for bladder retraining due to urge incontinence. However, she reports that her symptoms have not improved and the incontinence is becoming increasingly bothersome and embarrassing. She is interested in exploring other treatment options, but expresses concerns about potential medication side effects on her memory. What would be the most suitable next step in managing her symptoms?
Your Answer: Mirabegron
Explanation:When it comes to managing urge incontinence, anticholinergics like solifenacin and oxybutynin can cause confusion in elderly patients, making them less suitable for those with cognitive impairment. Instead, mirabegron, a beta-3 adrenergic agonist, is a better alternative that can effectively treat urge incontinence without the risk of anticholinergic side effects. Long-term catheterisation and fluid restriction should not be considered as viable options for managing incontinence.
Urinary incontinence is a common condition that affects approximately 4-5% of the population, with elderly females being more susceptible. There are several risk factors that can contribute to the development of urinary incontinence, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. The condition can be classified into different types, such as overactive bladder, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.
Initial investigation of urinary incontinence involves completing bladder diaries for at least three days, performing a vaginal examination to exclude pelvic organ prolapse, and conducting urine dipstick and culture tests. Urodynamic studies may also be necessary. Management of urinary incontinence 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 may be necessary. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be offered to women who decline surgical procedures.
In summary, urinary incontinence is a common condition that can be caused by various risk factors. It can be classified into different types, and management depends on the predominant type of incontinence. Initial investigation involves completing bladder diaries, performing a vaginal examination, and conducting urine tests. Treatment options include bladder retraining, bladder stabilizing drugs, pelvic floor muscle training, surgical procedures, and duloxetine.
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This question is part of the following fields:
- Kidney And Urology
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Question 14
Correct
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A 40-year-old man presents with painless blood staining of the semen upon ejaculation. He reports no recent unprotected sexual intercourse and is in good health otherwise.
What is the most probable diagnosis? Choose ONE answer.Your Answer: Idiopathic and self-limiting
Explanation:Understanding Haematospermia: Causes and Symptoms
Haematospermia, the presence of blood in the ejaculate, is a common and usually benign symptom that can affect men of any age. In about 50% of cases, the cause is unknown and the symptom is self-limiting. However, further investigation may be necessary for men over 40 or those with accompanying symptoms such as perineal pain or abnormal examination findings.
Other conditions, such as urinary tract infections, epididymitis, hypertension, and prostate cancer, can also cause haematospermia. However, these conditions are usually accompanied by other symptoms such as dysuria, testicular pain, urinary symptoms, penile discharge, headaches, visual disturbance, or are unlikely in a 35-year-old man without any other symptoms.
It is important to seek medical attention if haematospermia persists or is accompanied by other symptoms.
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This question is part of the following fields:
- Kidney And Urology
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Question 15
Correct
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A 6-month-old boy was thought to have a unilateral undescended testicle at birth. At 6 months, the testicle is palpable in the inguinal canal, but cannot be brought down into the scrotum.
What is the most appropriate management option?
Your Answer: Surgery at 6 months
Explanation:Undescended Testicles in Infants: Diagnosis and Treatment Options
Undescended testicles, also known as cryptorchidism, is a common condition in male infants where one or both testicles fail to descend into the scrotum. This can lead to potential complications such as infertility and an increased risk of testicular cancer.
The recommended course of action is to refer the infant to paediatric surgery or urology before six months of age. The current recommended timing for surgery is before 12 months of life to preserve the stem cells for subsequent spermatogenesis. However, even with surgical treatment, long-term outcomes remain problematic with impaired fertility and an increased cancer risk.
If one or both testicles are retractile, annual follow-up throughout childhood is advised due to the risk of ascending testis syndrome. Hormone treatment is an option, but it has a lower success rate and more adverse effects compared to surgery.
For cases where a single testis is undescended, a referral to paediatric surgery or urology should be made by six months of age if the testis has not descended. It is important to review the surgical option after 12 months of age.
Early diagnosis and prompt treatment are crucial in managing undescended testicles in infants.
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This question is part of the following fields:
- Kidney And Urology
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Question 16
Correct
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A mother presents to the General Practitioner with her 5-day-old son. She believes his scrotum looks abnormal and is worried that he has an undescended testicle.
Which of the following is the most appropriate method of diagnosis?Your Answer: Physical examination
Explanation:An undescended testis occurs when a testis is not present in the scrotum. This can be due to various reasons such as testicular maldescent, retractile testes, ascending testis syndrome, or testicular agenesis. To diagnose this condition, physical examination is recommended, and the testes can be categorized as palpable or non-palpable. Magnetic resonance imaging is not necessary as physical examination is cheaper, faster, and more accessible. Parental history may raise concern, but physical examination is still necessary for confirmation. Diagnostic laparoscopy can be used to investigate the underlying cause of undescended testes, but it is not used for diagnosis. Ultrasound scanning is not recommended for routine evaluation as it is not accurate enough to reliably detect or confirm the absence of an impalpable testis.
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This question is part of the following fields:
- Kidney And Urology
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Question 17
Correct
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Mr. Johnson is a 65-year-old man with multiple sclerosis who has a long term catheter. He was admitted to hospital following a fall and discharged the next day. As part of his work up in the emergency department his urine was sent off for culture.
You receive a letter in your inbox with the urine culture results:
Escherichia coli sensitive to amoxicillin, nitrofurantoin, trimethoprim
You note that he is penicillin allergic. You call Mr. Johnson to find out how he is, however he denies any urinary symptoms or haematuria. There is no blockage and his catheter is draining well.
How will you best manage Mr. Johnson?Your Answer: No treatment needed
Explanation:NICE guidelines advise against the routine treatment of asymptomatic bacteriuria in catheterised patients. Treatment should only be given if the patient is experiencing symptoms. In such cases, a 7-day course of antibiotics may be prescribed, and the catheter may be changed if necessary. However, removal of the catheter is not an option for long-term catheterised patients. If sepsis is suspected, the patient should be referred to a hospital for intravenous antibiotics.
Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. Lower UTIs are more common and can be managed with antibiotics. For non-pregnant women, local antibiotic guidelines should be followed, and a urine culture should be sent if they are aged over 65 years or have visible or non-visible haematuria. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. Pregnant women with symptoms should have a urine culture sent, and first-line treatment is nitrofurantoin, while amoxicillin or cefalexin can be used as second-line treatment. Asymptomatic bacteriuria in pregnant women should also be treated with antibiotics. Men with UTIs should be offered antibiotics for seven days, and a urine culture should be sent before starting treatment. Catheterised patients should not be treated for asymptomatic bacteria, but if they are symptomatic, a seven-day course of antibiotics should be given, and the catheter should be removed or changed if it has been in place for more than seven days. For patients with signs of acute pyelonephritis, hospital admission should be considered, and local antibiotic guidelines should be followed. The BNF recommends a broad-spectrum cephalosporin or a quinolone for 10-14 days for non-pregnant women.
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This question is part of the following fields:
- Kidney And Urology
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Question 18
Correct
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A 30-year-old patient who has been under your care for four years contacts you over the phone, requesting antibiotics for a suspected UTI. She complains of dysuria and frequency for the past two days and had a confirmed UTI with the same symptoms last year. As per GMC guidelines, what would be the most suitable course of action?
Your Answer: Antibiotics can be prescribed, with normal safeguards and advice
Explanation:GMC Guidelines for Prescribing and Managing Medicines and Devices
Prescribing and managing medicines and devices is a crucial aspect of a doctor’s role. The General Medical Council (GMC) has published guidelines for good practice in prescribing medicines, which were last updated in 2008. The principles of prescribing include only prescribing drugs to meet the identified needs of patients and avoiding treating oneself or those close to them. Doctors with full registration may prescribe all medicines except those in Schedule 1 of the Misuse of Drugs Regulations 2001.
To ensure that doctors prescribe in patients’ best interests, the guidelines recommend keeping up to date with the British National Formulary (BNF), National Institute for Health and Care Excellence (NICE), and Scottish Intercollegiate Guidelines Network (SIGN). Doctors should also report adverse reactions to medicines to the Committee on the Safety of Medicines through the Yellow Card Scheme. If a nurse or other healthcare professional without prescribing rights recommends a treatment, the doctor must ensure that the prescription is appropriate for the patient and that the professional is competent to have recommended it.
The guidelines also address doctors’ interests in pharmacies, emphasizing the importance of ensuring that patients have access to information about any financial or commercial interests the doctor or their employer may have in a pharmacy. When it comes to prescribing controlled drugs for oneself or someone close, doctors should avoid doing so whenever possible and should be registered with a GP outside their family. If no other person with the legal right to prescribe is available, doctors may prescribe a controlled drug only if it is immediately necessary to save a life, avoid serious deterioration in the patient’s health, or alleviate otherwise uncontrollable pain.
Finally, the guidelines provide recommendations for remote prescribing via telephone, email, fax, video link, or a website. While this is supported, doctors must give an explanation of the processes involved in remote consultations and provide their name and GMC number to the patient if they are not providing continuing care. By following these guidelines, doctors can ensure that they prescribe and manage medicines and devices in the best interests of their patients.
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This question is part of the following fields:
- Kidney And Urology
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Question 19
Correct
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A 48-year-old man presents to you with elevated blood pressure. He has a history of chronic kidney disease and his estimated glomerular filtration rate was 53 ml/min six weeks ago. His albumin:creatinine ratio was 35 mg/mmol. He denies experiencing any chest pain or shortness of breath. Upon examination, his blood pressure is 172/94 mmHg and fundoscopy is unremarkable. What is the optimal course of treatment?
Your Answer: Ramipril
Explanation:Patients who have chronic kidney disease, hypertension, and an albumin:creatinine ratio exceeding 30 mg/mmol should be initiated on a renin-angiotensin antagonist. These medications have been proven to have positive impacts on both cardiovascular outcomes and renal function. While the other drugs are also utilized for hypertension, they do not offer the same advantages and are not the primary choice for individuals with 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 especially effective in proteinuric renal disease like diabetic nephropathy. However, these drugs can reduce filtration pressure, leading to a slight decrease in glomerular filtration pressure (GFR) and an increase in creatinine. NICE guidelines state that 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. If the rise is greater than this, it may indicate underlying renovascular disease.
Furosemide is a useful Antihypertensive drug for CKD patients, particularly 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 is at risk of dehydration (e.g. due to gastroenteritis), the drug should be temporarily stopped. The NKF K/DOQI guidelines suggest a lower cut-off of less than 30 ml/min.
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This question is part of the following fields:
- Kidney And Urology
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Question 20
Correct
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You receive a fax through from urology. One of your patients in their 50s with a raised PSA recently underwent a prostatic biopsy. The report reads as follows:
Adenocarcinoma prostate, Gleason 3+4
Which one of the following statements regarding the Gleason score is incorrect?Your Answer: The lower the Gleason score the worse the prognosis
Explanation:Prognosis of Prostate Cancer Based on Gleason Score
Prostate cancer prognosis can be predicted using the Gleason score, which is determined through histology following a hollow needle biopsy. The Gleason score is based on the glandular architecture seen on the biopsy and is calculated by adding the most prevalent and second most prevalent patterns observed. This results in a Gleason grade ranging from 1 to 5, which is then added together to obtain a Gleason score ranging from 2 to 10. The higher the Gleason score, the worse the prognosis for the patient. Therefore, the Gleason score is an important factor in determining the appropriate treatment plan for patients with prostate cancer.
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This question is part of the following fields:
- Kidney And Urology
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Question 21
Incorrect
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A 62-year-old man presents to his General Practitioner with bothersome urinary symptoms of urinary frequency, nocturia and hesitancy. His International Prostate Symptom Score (IPSS) is 20/35. A recent digital rectal examination (DRE) shows a smoothly enlarged prostate. His blood test results show a prostate-specific antigen (PSA) level of 3.5 ng/ml (age-specific normal range for ages 60-69: < 4.0 ng/ml). What is the most appropriate initial treatment?
Your Answer: Finasteride
Correct Answer: Tamsulosin and finasteride
Explanation:This man is experiencing symptoms of benign prostatic hyperplasia (BPH), which is common in men over 45 years old and presents with urinary frequency, nocturia, and hesitancy. Upon examination, his prostate is enlarged but his PSA is normal. Based on his moderate voiding symptoms, he should receive combination therapy with an alpha-blocker (such as tamsulosin) and a 5-alpha-reductase inhibitor (such as finasteride). Finasteride works to physically reduce the size of the prostate, but may take up to six months to show improvement, while the alpha-blocker works quickly to relieve symptoms but has no long-term impact. For patients at high risk of progression, a 5-alpha-reductase inhibitor alone should be offered. It is important to counsel patients about common side-effects, including erectile dysfunction and safety issues. Goserelin is not appropriate in this case as it is used in the treatment of prostate cancer. Oxybutynin may be added for patients with a mixture of storage and voiding symptoms that persist after treatment with an alpha-blocker. Tamsulosin alone may be offered for those with mild symptoms not responding to conservative management or those who decline treatment with finasteride. Common side-effects of tamsulosin include dizziness and sexual dysfunction, and it should be used with caution in the elderly and those with a history of postural hypotension or micturition syncope.
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This question is part of the following fields:
- Kidney And Urology
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Question 22
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A 50-year-old man presents to the General Practitioner with a painful, persistent erection that has lasted for six hours and doesn't subside. What is the most likely cause of his symptoms? Choose ONE answer.
Your Answer: Sickle cell disease
Explanation:Understanding Priapism: Causes and Types
Priapism is a medical condition characterized by prolonged and painful erections that can last for several hours. There are two types of priapism: low-flow (ischaemic) and high-flow (arterial). Low-flow priapism is the most common type and is often associated with sickle cell disease, leukaemia, thalassemia, and other medical conditions. It is caused by the inadequate return of blood from the penis, resulting in a rigid erection. High-flow priapism, on the other hand, is less common and is usually caused by a ruptured artery from a blunt injury to the penis or perineum.
Stuttering priapism is a distinct condition that is characterized by repetitive and painful episodes of prolonged erections. It is a type of low-flow priapism and is often associated with sickle cell disease. The duration of the erectile episodes in stuttering priapism is generally shorter than in the low-flow ischaemic type.
Other medical conditions that can cause priapism include glucose-6-phosphate dehydrogenase deficiency, Fabry’s disease, neurologic disorders, such as spinal cord lesions and spinal cord trauma, and neoplastic diseases, such as prostate, bladder, testicular, and renal cancer and myeloma. Many drugs can also cause priapism, but nearly 50% of cases are idiopathic.
In conclusion, priapism is a serious medical condition that requires prompt medical attention. Understanding the causes and types of priapism can help individuals seek appropriate treatment and prevent complications.
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This question is part of the following fields:
- Kidney And Urology
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Question 23
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You are conducting an annual medication review for a 70-year-old female patient with a medical history of hypertension and a myocardial infarction 6 years ago. During her blood test taken a week ago, her estimated glomerular filtration rate (eGFR) was found to be 45 mL/min/1.73 m2, indicating reduced kidney function and a possible diagnosis of chronic kidney disease (CKD). The patient is curious about what other tests are needed to confirm CKD, aside from repeating her kidney function test in 3 months. What other tests should be recommended?
Your Answer: She should bring in an early morning urine sample to be dipped for haematuria and sent for urine ACR calculation
Explanation:To diagnose CKD in a patient with an eGFR <60, it is necessary to measure the creatinine level in the blood, obtain an early morning urine sample for ACR testing, and dip the urine for haematuria. CKD is confirmed when these tests show a persistent reduction in kidney function or the presence of proteinuria (ACR) for at least three months. Proteinuria is a significant risk factor for cardiovascular disease and mortality, and an early morning urine sample is preferred for ACR analysis. The patient should provide another blood sample after 90 days to confirm the diagnosis of CKD. Chronic kidney disease is often without symptoms and is typically identified through abnormal urea and electrolyte levels. However, some individuals with advanced, undetected disease may experience symptoms. These symptoms may include swelling in the ankles, weight gain, increased urination, fatigue, itching due to uraemia, loss of appetite leading to weight loss, difficulty sleeping, nausea and vomiting, and high blood pressure.
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This question is part of the following fields:
- Kidney And Urology
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Question 24
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A 65-year-old man presents with a 72-hour history of lower abdominal pain, dysuria, and frequent urination. He has no prior history of urinary issues and no significant medical history. Upon urine dipstick testing, leucocytes and nitrites are positive while blood and protein are negative. What is the next best course of action for managing this patient?
Your Answer: Prescribe oral antibiotics
Explanation:According to NICE guidelines, men with symptoms of a lower UTI should receive oral antibiotics such as trimethoprim or nitrofurantoin, based on local microbiology protocols. This patient’s dipstick test is positive for nitrites, indicating a UTI, and he should be treated accordingly.
Intravenous antibiotics are not typically necessary for UTI treatment unless the patient experiences rigors, chills, vomiting, or confusion. Therefore, this option is not appropriate for this patient.
Men with UTIs should not be routinely referred to urology unless the infection is recurrent. The two-week rule pathway should be followed for patients aged 45 and over with unexplained visible haematuria or aged 60 and over with unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test.
While it may be important to rule out a sexually transmitted infection, this patient’s symptoms suggest a UTI, and there is no indication of an STI in his medical history. Therefore, empirical antibiotics should be administered initially.
Although it is important to perform a urinary MC+S test to assess for resistant bacteria, antibiotic treatment should not be delayed while waiting for the results. In this case, prompt treatment is necessary to prevent the infection from spreading or causing sepsis.
Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. Lower UTIs are more common and can be managed with antibiotics. For non-pregnant women, local antibiotic guidelines should be followed, and a urine culture should be sent if they are aged over 65 years or have visible or non-visible haematuria. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. Pregnant women with symptoms should have a urine culture sent, and first-line treatment is nitrofurantoin, while amoxicillin or cefalexin can be used as second-line treatment. Asymptomatic bacteriuria in pregnant women should also be treated with antibiotics. Men with UTIs should be offered antibiotics for seven days, and a urine culture should be sent before starting treatment. Catheterised patients should not be treated for asymptomatic bacteria, but if they are symptomatic, a seven-day course of antibiotics should be given, and the catheter should be removed or changed if it has been in place for more than seven days. For patients with signs of acute pyelonephritis, hospital admission should be considered, and local antibiotic guidelines should be followed. The BNF recommends a broad-spectrum cephalosporin or a quinolone for 10-14 days for non-pregnant women.
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This question is part of the following fields:
- Kidney And Urology
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Question 25
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A 60-year-old woman presents with swollen legs and is diagnosed with proteinuria. Identify the one characteristic that would strongly indicate a diagnosis of nephrotic syndrome instead of nephritic syndrome.
Your Answer: Proteinuria > 3.5g/24 hours
Explanation:Understanding Nephrotic Syndrome and Nephritic Syndrome
Nephrotic syndrome is a condition characterized by proteinuria, hypoalbuminemia, edema, and hyperlipidemia. On the other hand, nephritic syndrome is defined by azotemia, hematuria, hypertension, and oliguria. Both syndromes present with edema, but the amount of proteinuria is higher in nephrotic syndrome.
In nephrotic syndrome, the glomerulus has small pores that allow protein to pass through but not cells, resulting in proteinuria and hypoalbuminemia. The liver compensates for protein loss by increasing the synthesis of albumin, LDL, VLDL, and lipoprotein(a), leading to lipid abnormalities. Patients with nephrotic syndrome are also at risk of hypercoagulability and infection due to the loss of inhibitors of coagulation and immunoglobulins in the urine.
The etiology of nephrotic syndrome varies depending on age and comorbidities. Minimal change disease is the most common cause in children, while focal segmental glomerulosclerosis is the most common cause in younger adults. Membranous nephropathy is the most common cause in older people, and diabetic nephropathy in adults with long-standing diabetes. Secondary causes include amyloidosis, lupus nephritis, and multiple myeloma.
Categorizing glomerular renal disease into syndromes such as nephrotic syndrome and nephritic syndrome helps narrow the differential diagnosis. Understanding the differences between these two syndromes is crucial in the diagnosis and management of glomerular renal disease.
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This question is part of the following fields:
- Kidney And Urology
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Question 26
Correct
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A 60-year-old man comes to your clinic complaining of fatigue and swelling in his legs. Upon conducting some blood tests, the following results are obtained:
- Sodium (Na+): 138 mmol/l
- Potassium (K+): 5.6 mmol/l
- Urea: 19.3 mmol/l
- Creatinine: 299 µmol/l
It is noted that his renal function was normal six months ago. Which of his regular medications should be stopped immediately?Your Answer: Ibuprofen
Explanation:Patients with acute kidney injury or chronic kidney disease should avoid NSAIDs like ibuprofen as they can exacerbate renal impairment.
Prescribing for Patients with Renal Failure
Prescribing medication for patients with renal failure can be challenging. It is important to know which drugs to avoid and which ones require dose adjustment. Antibiotics such as tetracycline and nitrofurantoin, as well as NSAIDs, lithium, and metformin should be avoided in patients with renal failure. These drugs can cause further damage to the kidneys or accumulate in the body, leading to toxicity.
On the other hand, some drugs require dose adjustment in patients with chronic kidney disease. Antibiotics such as penicillins, cephalosporins, vancomycin, gentamicin, and streptomycin, as well as digoxin, atenolol, methotrexate, sulphonylureas, and furosemide, are among the drugs that require dose adjustment. Opioids should also be used with caution in patients with renal failure.
There are also drugs that are relatively safe to use in patients with renal failure. Antibiotics such as erythromycin and rifampicin, as well as diazepam and warfarin, can sometimes be used at normal doses depending on the degree of chronic kidney disease.
In summary, prescribing medication for patients with renal failure requires careful consideration of the drugs’ potential effects on the kidneys and the need for dose adjustment. It is important to consult with a healthcare provider to ensure safe and effective medication management for these patients.
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This question is part of the following fields:
- Kidney And Urology
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Question 27
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A woman who is 32 weeks pregnant presents with acute left sided pyelonephritis. She has a history of recurrent urinary tract infection as a child. Her blood pressure is 145/85. Investigations reveal: creatinine 58 μmol/l (Third trimester reference values 35-62 μmol/l).
Select the single most likely cause.Your Answer: Reflux nephropathy
Explanation:Reflux Nephropathy: A Condition Causing Kidney Damage
Reflux nephropathy is a condition that occurs in some children and infants where the vesico-ureteric junction allows urine to flow back up the ureters during bladder contraction. This can lead to incomplete bladder emptying and infection, which can cause kidney damage. The damage can be variable and unilateral, with papillary damage, interstitial nephritis, and cortical scarring in the affected kidney. As the child grows, infections usually stop, but hypertension may develop, and in severe cases, renal damage may be progressive, leading to chronic renal failure.
During pregnancy, there is an increased glomerular filtration rate (GFR), which can cause both urea and creatinine levels to decrease. However, dilatation of the ureters and pelvis during pregnancy can lead to urinary stasis and an increased risk of developing urinary tract infections. In cases where there is a history of reflux, it is likely that reflux nephropathy is the cause of kidney damage. Hypertension and renal failure are common features of this condition, but the presence of infection points to reflux as the underlying cause.
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This question is part of the following fields:
- Kidney And Urology
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Question 28
Correct
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A 63-year-old man presents to the emergency department with a three day history of feeling unwell, dysuria, and increased frequency of urination. He denies any macroscopic hematuria. Upon further questioning, he reports having long-standing lower urinary tract symptoms such as weakened urinary stream, hesitancy, urgency, and nocturia for the past year, which have slowly worsened. On examination, he appears well with no abdominal or loin tenderness. Urine dipstick shows nitrites positive and leukocytes+++. A diagnosis of urinary tract infection is made, and he is treated with oral antibiotics. The patient expresses interest in having a digital rectal examination and prostate-specific antigen (PSA) blood test to evaluate his lower urinary tract symptoms. A digital rectal examination reveals a smoothly enlarged benign-feeling prostate. When would be the most appropriate time to perform a PSA blood test in this case?
Your Answer: Postpone the test for at least 48 hours
Explanation:Factors Affecting Prostate-Specific Antigen Blood Test
The prostate-specific antigen (PSA) blood test is a common diagnostic tool used to detect prostate cancer. However, the test results can be influenced by various factors, including benign prostatic hypertrophy, prostatitis, urinary retention, urinary tract infection, old age, urethral or rectal instrumentation/examination, recent vigorous exercise, and recent ejaculation.
It is important to note that the PSA test should be deferred for at least a month in individuals with a proven urinary tract infection. Additionally, if a man has ejaculated or exercised vigorously in the previous 48 hours, the test should also be deferred. While some sources suggest delaying PSA testing for at least a week after a digital rectal examination, data suggest that rectal examination has minimal effect on PSA levels.
In summary, it is crucial to consider these factors when interpreting PSA test results to ensure accurate diagnosis and treatment.
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This question is part of the following fields:
- Kidney And Urology
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Question 29
Correct
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A 45-year-old man with no previous medical history of note attends for a new patient check. His blood pressure is noted to be 152/100 mmHg so you arrange blood tests. The results include an eGFR of 55.
Select the single correct diagnosis that can be made in this case.Your Answer: None of the above
Explanation:Diagnosis of CKD and Hypertension: NICE Guidelines
The National Institute for Health and Care Excellence (NICE) has provided guidelines for the diagnosis of chronic kidney disease (CKD) and hypertension. To diagnose CKD, more than one estimated glomerular filtration rate (eGFR) reading below 60 is required over a period of three months. Similarly, hypertension should not be diagnosed based on a single blood pressure reading, but rather through ambulatory or home blood pressure monitoring. Acute kidney injury is characterized by a significant increase in serum creatinine or oliguria, and eGFR is not a reliable indicator for its diagnosis. NICE also recommends using eGFRcystatinC to confirm or rule out CKD in individuals with an eGFR of 45-59 ml/min/1.73 m2, sustained for at least 90 days, and no proteinuria or other markers of kidney disease.
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This question is part of the following fields:
- Kidney And Urology
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Question 30
Correct
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You are evaluating a 58-year-old man with lower urinary tract symptoms. He presented six months ago with complaints of weak urinary stream, hesitancy, intermittency, terminal dribbling, and nocturia ×2. He denies any history of visible haematuria or erectile dysfunction. Urine dipstick testing is normal, his eGFR is stable at 84, and his PSA is 0.9 ng/mL. On digital rectal examination, his prostate is less than 30 g in size with no sinister features.
Despite conservative management and modification of his fluid intake, his symptoms persist and he has returned seeking advice on taking a tablet. His international prostate symptom score was 17 at his initial visit and is now 15. He reports that his quality of life is affected by his urinary symptoms and he is unhappy. He is otherwise healthy and not taking any other medications.
What is the most appropriate initial pharmacological approach for this patient's symptoms?Your Answer: Finasteride 5 mg OD and oxybutynin 5 mg BD
Explanation:NICE Guidelines for Drug Treatment of Lower Urinary Tract Symptoms
NICE recommends drug treatment for bothersome lower urinary tract symptoms (LUTS) if conservative measures fail. For moderate to severe LUTS, an alpha-blocker like tamsulosin should be offered. Patients should be reviewed after four to six weeks until stable. If LUTS is accompanied by an enlarged prostate or a high PSA level, a 5-alpha reductase inhibitor like finasteride should be prescribed. Anticholinergic drugs like oxybutynin can be used to manage storage symptoms. For patients with moderate to severe LUTS and an enlarged prostate or high PSA level, both an alpha-blocker and a 5-alpha reductase inhibitor can be started. In the case of a patient with moderate LUTS, a prostate less than 30 g, and a PSA level less than 1.4, starting an alpha-blocker like tamsulosin and reviewing the patient in four to six weeks is the most appropriate approach.
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This question is part of the following fields:
- Kidney And Urology
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