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Question 1
Incorrect
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A 72-year-old man is recovering from hip surgery on the ward. He has had an indwelling catheter for several days. In the last 24 hours, he has been noted to have some ‘dizzy spells’ by nurses where he becomes confused and agitated. He has been seen talking to himself, mumbling incoherent ideas, and at other times he seems distracted and disorientated, forgetting where he is. He has a new fever and is tachycardic. The rest of the examination is unremarkable. You suspect he is suffering from delirium.
Which one of the following is most likely to be found in this patient?Your Answer: Progressive decline in cognitive function
Correct Answer: Leukocytes and nitrites on mid-stream urine sample dipstick
Explanation:Understanding Delirium: Causes and Symptoms
Delirium is a state of confusion that can be caused by various factors, including acute illnesses, infections, drug adverse reactions, and toxicity. In this scenario, the patient’s symptoms of fever and an indwelling catheter increase the likelihood of a urinary tract infection (UTI) as the cause of delirium. Other causes of delirium include drug-related issues, alcohol withdrawal, metabolic imbalances, and head injury or trauma.
Symptoms of delirium include leukocytes and nitrites on a mid-stream urine sample dipstick, which suggest a UTI. However, a frozen or ‘mask-like’ face is commonly associated with Parkinson’s disease, not delirium. Structural changes in the brain are usually associated with dementia, while a progressive decline in cognitive function may indicate a space-occupying lesion or bleed (extradural haematoma).
It is important to note that cognitive changes caused by delirium are often reversible by finding and treating the underlying cause. In contrast, irreversible cognitive changes are commonly seen in dementia. Understanding the causes and symptoms of delirium can help healthcare professionals provide appropriate care and treatment for patients experiencing this condition.
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This question is part of the following fields:
- Urology
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Question 2
Incorrect
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A 35-year-old man presents with a right inguinal mass. Upon examination, the left testis is found to be normal in size and position, but the right testis cannot be palpated in the scrotum. An ultrasound confirms that the inguinal mass is a cryptorchid testis.
What is the best course of action for addressing this patient's testicular anomaly?Your Answer: Put it into the scrotum surgically (orchidopexy)
Correct Answer: Remove it (orchidectomy)
Explanation:Options for Managing Cryptorchidism
Cryptorchidism, or undescended testis, is a condition where one or both testes fail to descend into the scrotum. Here are some options for managing this condition:
1. Orchidectomy: This involves removing the undescended testis, which eliminates the risk of developing seminoma. If the patient is 30 years old or older, the undescended testis is unlikely to be capable of spermatogenesis, so removal should not affect fertility.
2. Bilateral orchidectomy: This involves removing both testes, but it is not necessary if only one testis is undescended. The opposite testis is not affected by the undescended testis and should be left intact.
3. Orchidopexy: This is a surgical procedure to place the undescended testis in the scrotum. It is most effective when done before the age of 2, but it does not reduce the risk of developing testicular cancer.
4. Testosterone therapy: This is not necessary for patients with cryptorchidism, as the Leydig cells in the testicular interstitium continue to produce testosterone.
5. Chromosome analysis: This is indicated if there is a suspicion of a chromosomal defect, such as testicular feminisation or Klinefelter syndrome.
In summary, the management of cryptorchidism depends on the individual case and should be discussed with a healthcare provider.
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This question is part of the following fields:
- Urology
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Question 3
Incorrect
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A 40-year-old man presents with blood in his ejaculate. He reports no lower urinary tract symptoms and no abdominal pain and is generally healthy. He has been in a long-term monogamous relationship and denies any history of trauma. Examination of his scrotum and penis is unremarkable, and his prostate is normal and non-tender upon digital rectal examination. Urinalysis results are within normal limits, and there is no family history of cancer.
What is the most appropriate next step, in addition to obtaining a urine sample for microscopy, culture, and sensitivities?Your Answer: Arrange a prostate-specific antigen (PSA) blood test
Correct Answer: Reassure him that this symptom is not a sign of anything serious but ask him to return if he has >3 episodes or the problem persists for over a month
Explanation:Haematospermia, or blood in semen, is usually not a cause for concern in men under 40 years old. The most common causes are trauma, urinary tract infection (especially prostatitis), and sexually transmitted infection. However, it is important to rule out cancer through appropriate physical examination. If the symptom persists for over a month or there are more than three episodes, referral is recommended, especially for men over 40 years old. While reassurance is appropriate, patients should be encouraged to seek medical attention if the problem persists. Antibiotics may be prescribed if a urinary tract infection is suspected, but this is unlikely in cases with normal urinalysis. Urgent referral is necessary for men with signs and symptoms suggestive of prostate or urological malignancies, or if the underlying cause of haematospermia may be cysts or calculi of the prostate or seminal vesicles.
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This question is part of the following fields:
- Urology
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Question 4
Correct
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A male toddler, on physical examination at the age of 2, is noticed to have an abnormal opening of the urethra on to the ventral surface of the penis.
Which of the following is the most likely diagnosis?Your Answer: Hypospadias
Explanation:Common Congenital Penile Deformities and Conditions
Hypospadias, Cryptorchidism, Exstrophy, Epispadias, and Phimosis are all congenital penile deformities and conditions that affect newborn boys. Hypospadias is the most common, occurring in about 1 in every 150-300 boys. It is characterized by an abnormal opening of the urethral meatus on the ventral surface of the penis, ventral curvature of the penis, and a hooded foreskin. Cryptorchidism, on the other hand, is the failure of the testes to descend into the scrotal sac and is seen in 3% of all full-term newborn boys. Exstrophy is a rare condition where the bladder protrudes through a defect in the lower abdominal wall. Epispadias is defined as an abnormal opening of the urethra on the dorsal aspect of the penis, while Phimosis is a condition where the foreskin cannot be fully retracted over the glans of the penis. These conditions may have genetic components and can lead to complications such as infection, urinary tract obstruction, and other associated conditions.
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This question is part of the following fields:
- Urology
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Question 5
Incorrect
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A 58-year-old man with long-standing multiple sclerosis (MS) is admitted due to increasing problems with his care in the community. He is bed-bound with a spastic paraparesis. He is noted to have a permanent 14-gauge urinary catheter in situ and has a history of recurrent urinary tract infections. The family informs the nursing staff that this has not been changed for some time. Your senior colleague wishes for the catheter to be replaced due to recurrent UTIs.
Which one of the following statements is the most accurate?Your Answer: A male chaperone is required
Correct Answer: A single dose of prophylactic gentamicin is advisable
Explanation:Best Practices for Permanent Indwelling Urinary Catheters
Introduction:
Permanent indwelling urinary catheters are commonly used in patients with urinary retention or incontinence. However, they can pose a risk of infection and other complications. Therefore, it is important to follow best practices when placing and maintaining these catheters.Prophylactic Gentamicin:
When replacing a permanent catheter, it is recommended to administer a single dose of prophylactic gentamicin to prevent infection.Regular Replacement:
It is essential to have measures in place for regular routine replacement of permanent catheters. This is because they are a foreign body and can be a portal of entry for infection. Urinary sepsis in these patients can be devastating and fatal.Same-Sized Catheter:
When replacing a catheter, it is not necessary to change the size unless there are symptoms of catheter bypass. Increasing the size can cause pain and trauma.Local Anaesthetic Gel:
Even if a patient has paraparesis, local anaesthetic gel must be used during catheter insertion to prevent pain.Chaperone:
It is good practice to offer a chaperone during any intimate examination/procedure. The patient may accept or decline a chaperone. If a chaperone is required, they do not have to be a man as long as there is consent from the patient.Regular Replacement Schedule:
Long-term catheters require changing every 12 weeks due to the design of the catheter and the risk of infection. This can be done in the community by district nurses.Best Practices for Permanent Indwelling Urinary Catheters
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This question is part of the following fields:
- Urology
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Question 6
Incorrect
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A 19-year-old man comes to the clinic complaining of a painful swelling in the area of his glans penis that has been present for 6 hours. Upon examination, the glans penis is red, oedematous, and extremely tender. The foreskin is pulled back, but there is no evidence of scrotal or penile necrosis or redness.
What is the best course of action for treatment?Your Answer: Swab the area for microscopy and culture, and await the result before deciding on treatment
Correct Answer: Soak the foreskin and glans penis in a hypertonic solution and attempt to manually replace the foreskin by using gentle, but sustained, distal traction
Explanation:Management of Penile Conditions: Differentiating Paraphimosis and Balanitis
Penile conditions such as paraphimosis and balanitis require prompt and appropriate management. Paraphimosis occurs when the foreskin is retracted but cannot be replaced, leading to swelling of the glans penis. This is a urological emergency that requires immediate intervention. Treatment involves attempting to manually reduce the foreskin, aided by a hypertonic solution to draw out fluid from the swollen area. Referral to Urology is necessary if reduction is not successful.
Balanitis, on the other hand, is inflammation of the foreskin usually caused by dermatitis or infection with Candida, Gardnerella, or staphylococcal organisms. Symptoms include tenderness and erythema of the glans penis, itching, penile discharge, difficulty with retraction of the foreskin, and difficulty urinating or controlling urine stream. Treatment involves prescribing a 7-day course of hydrocortisone and clotrimazole cream or flucloxacillin if caused by Staphylococcus aureus.
It is important to differentiate between these two conditions and provide appropriate management to prevent complications.
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This question is part of the following fields:
- Urology
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Question 7
Incorrect
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A 30-year-old woman presents to the Emergency Department with acute abdominal pain which started about six hours ago. She claims the pain is in the lower abdomen and has been worsening gradually. She has not been able to pass urine since before the pain started.
Upon examination, vital signs are stable and suprapubic tenderness is present. There is no rebound tenderness, and the examining doctor does not find any signs of peritonitis. In addition, the doctor finds a large solid abdominal mass in the right lower quadrant. The patient said this mass had been there for a few years and has made it difficult to get pregnant. The patient also claims that she has heavy periods. She is due to have an operation for it in two months. A serum pregnancy test is negative.
Which of the following is the most likely diagnosis requiring immediate treatment and admission?Your Answer: Ovarian cyst
Correct Answer: Acute urinary retention
Explanation:Possible Diagnoses for a Patient with Acute Urinary Retention and an Abdominal Mass
During this admission, the patient presents with symptoms consistent with acute urinary retention, including sudden onset of symptoms and suprapubic tenderness. The presence of an abdominal mass suggests a possible gynecological cause, such as a uterine fibroid. However, it is important to note that if cancer is suspected, the patient would be referred for investigation under the 2-week cancer protocol, but the acute admission is required for urinary retention and catheterization.
Other possible diagnoses, such as ovarian cyst, appendicitis, and caecal tumor, are less likely based on the patient’s symptoms and presentation. While a uterine fibroid may be a contributing factor to the urinary retention, it is not the primary reason for the admission. Overall, a thorough evaluation is necessary to determine the underlying cause of the patient’s symptoms and provide appropriate treatment.
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This question is part of the following fields:
- Urology
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Question 8
Correct
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A 58-year-old man presents to his Emergency Department complaining of blood in his urine. He reports that this has been happening over the past three days. He denies any pain or fever.
Physical examination revealed bilateral wheezes but is otherwise unremarkable. He does not have any problem passing urine. He has always lived in the UK and has not travelled anywhere outside the country recently. The patient is retired but used to work in a textile factory where he was responsible for working in the dye plants producing different coloured fabric. He has a past medical history of chronic obstructive pulmonary disease (COPD) and hypertension. He takes losartan for his hypertension and a budesonide and formoterol combination inhaler for his COPD. The man is an ex-smoker with a 30 pack-year smoking history.
What is the most likely diagnosis in this patient?Your Answer: Bladder cancer
Explanation:Differential Diagnosis for Painless Haematuria: Bladder Cancer vs. Other Possibilities
When a patient presents with painless haematuria, bladder cancer should be highly suspected until proven otherwise. While other conditions, such as urinary tract infections, can cause haematuria, a strong history of smoking and exposure to chemical dyes increase the likelihood of bladder cancer.
Prostate cancer is unlikely to present with haematuria and is more likely to be associated with lower urinary tract symptoms. Benign prostatic hyperplasia would present with signs of lower urinary tract obstruction, which this patient does not have. Nephrolithiasis can cause haematuria, but the absence of pain makes it less likely. Renal cancer may also present with haematuria, but it is more likely to be associated with loin or abdominal pain, weight loss, anaemia, and fatigue.
In summary, when a patient presents with painless haematuria and a history of smoking and exposure to chemical dyes, bladder cancer should be the primary concern. Other possibilities should be considered, but they are less likely based on the absence of additional symptoms.
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This question is part of the following fields:
- Urology
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Question 9
Correct
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A 67-year-old woman visits her GP complaining of urinary incontinence. She experiences this symptom throughout the day and has noticed that her urine flow is weak when she does manage to go voluntarily. During the examination, the GP detects a distended bladder despite the patient having just urinated before the appointment. What is the probable diagnosis for this woman's condition?
Your Answer: Urinary overflow incontinence
Explanation:The patient, an elderly woman, is experiencing urinary incontinence as evidenced by the palpable bladder even after urination. While prostate problems are a common cause of urinary overflow incontinence, this is not applicable in this case as the patient is a woman. Other possible causes include nerve damage resulting in a neurogenic bladder, which can be a complication of diabetes, chronic alcoholism, or pelvic surgery. The absence of a sudden urge to urinate rules out urge incontinence, while overactive bladder syndrome, a type of urge incontinence, is characterized by incontinence, frequent urination, and nocturia, which are not present in this case. Stress incontinence, which is associated with increased intraabdominal pressure, is also not observed. Therefore, a diagnosis of mixed incontinence is not warranted.
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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This question is part of the following fields:
- Urology
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Question 10
Correct
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A 32-year-old woman presents with a sudden-onset, severe, sharp, colicky pain in the right iliac fossa, radiating to the right loin and her right labia. Her last menstrual period was two weeks ago.
Which of the following would be most useful as an initial investigation?Your Answer: Urine dipstick
Explanation:Medical Procedures and Conditions: A Brief Overview
Urine Dipstick
In cases of suspected renal colic, a urine dipstick should be performed to support the diagnosis and rule out a urinary tract infection. Microscopic haematuria is a common indicator of renal stones.
Diagnostic Peritoneal Lavage (DPL)
DPL is a surgical diagnostic procedure used to detect free-floating fluid in the abdominal cavity, usually blood. It is now performed less frequently due to the increased use of other imaging modalities such as FAST and CT.
Blood Sugar Levels
Hypoglycaemia symptoms occur when blood sugar levels fall below 4 mmol/l. Symptoms include hunger, trembling, sweating, confusion, and difficulty concentrating. However, the history provided does not suggest hypoglycaemia or diabetes.
Rectal Examination
Digital rectal examination is commonly used to assess the prostate, detect rectal bleeding, and investigate constipation, changes in bowel habit, and problems with urinary or faecal continence. In exceptional circumstances, it may be used to detect the uterus and cervix.
Vaginal Examination
Speculum vaginal examination is commonly used to diagnose pregnancy, assess gestational age, detect abnormalities in the genital tract, investigate vaginal discharge, examine the cervix, and take cervical cytology smears.
Urinary Tract Infections (UTIs)
UTIs are caused by the presence of bacteria in the urinary tract and can affect the bladder, prostate, or kidneys. Escherichia coli is the most common cause. Abacterial cystitis, or the urethral syndrome, is a type of UTI that does not involve bacteriuria. Complicated and uncomplicated UTIs are differentiated by the presence or absence of renal tract and function abnormalities.
Overview of Common Medical Procedures and Conditions
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This question is part of the following fields:
- Urology
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