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  • Question 1 - A 66-year-old man is experiencing difficulty starting to urinate and frequently wakes up...

    Correct

    • A 66-year-old man is experiencing difficulty starting to urinate and frequently wakes up at night to use the bathroom. His PSA level is normal and a prostatic biopsy did not show any signs of cancer. What is the quickest treatment option to relieve his symptoms?

      Your Answer: Tamsulosin

      Explanation:

      Pharmacological Management of Benign Prostatic Hyperplasia

      Benign prostatic hyperplasia (BPH) is a common condition in older men that can cause urinary symptoms. Alpha-blockers, such as tamsulosin, are the first-line pharmacological treatment as they relax the smooth muscle of the bladder neck and improve urinary flow rates. Improvement in symptoms can be seen within a few days of therapy. Finasteride, an inhibitor of 5-alpha-reductase, can also be used to reduce prostatic volume over a period of around 6 months. However, it doesn’t provide rapid relief of symptoms. Cyproterone acetate and goserelin are not used in the treatment of BPH, as they are indicated for advanced prostate cancer. Oxybutynin, an antimuscarinic drug, can worsen symptoms of BPH and is not recommended for this condition.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 2 - What is the primary purpose of checking the urea and electrolytes before initiating...

    Incorrect

    • What is the primary purpose of checking the urea and electrolytes before initiating amiodarone therapy in a patient?

      Your Answer: To detect impaired renal function

      Correct Answer: To detect hypokalaemia

      Explanation:

      The risk of arrhythmias can be increased by all antiarrhythmic drugs, especially when hypokalaemia is present.

      Amiodarone is a medication used to treat various types of abnormal heart rhythms. It works by blocking potassium channels, which prolongs the action potential and helps to regulate the heartbeat. However, it also has other effects, such as blocking sodium channels. Amiodarone has a very long half-life, which means that loading doses are often necessary. It should ideally be given into central veins to avoid thrombophlebitis. Amiodarone can cause proarrhythmic effects due to lengthening of the QT interval and can interact with other drugs commonly used at the same time. Long-term use of amiodarone can lead to various adverse effects, including thyroid dysfunction, corneal deposits, pulmonary fibrosis/pneumonitis, liver fibrosis/hepatitis, peripheral neuropathy, myopathy, photosensitivity, a ‘slate-grey’ appearance, thrombophlebitis, injection site reactions, and bradycardia. Patients taking amiodarone should be monitored regularly with tests such as TFT, LFT, U&E, and CXR.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 3 - A 26-year-old woman who is 38 weeks' pregnant attends for a routine antenatal...

    Correct

    • A 26-year-old woman who is 38 weeks' pregnant attends for a routine antenatal check-up. Routine urine dipstick reveals blood and protein and urine culture is positive for Escherichia coli. She has no symptoms of urinary tract infection. A second specimen confirms the positive culture.
      What is the most appropriate course of action?

      Your Answer: Treat with amoxicillin

      Explanation:

      Management of Asymptomatic Bacteriuria in Pregnancy

      Asymptomatic bacteriuria is a common occurrence in pregnant women and can lead to complications such as pyelonephritis, pre-eclampsia, anaemia, and premature birth. Therefore, it is important to screen for and treat positive cultures in pregnant women. Tetracyclines, sulphonamides, and quinolones should be avoided, but alternatives such as amoxicillin, ampicillin, nitrofurantoin, and oral cephalosporins may be considered. Nitrofurantoin should be avoided near term due to the risk of haemolysis in the newborn. Repeat urine samples should be sent to ensure eradication. Referral to a specialist is not necessary unless there are other indications for specialist-led care. Trimethoprim should be avoided in the first trimester due to the risk of teratogenesis.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 4 - A patient with type 1 diabetes mellitus at the age of 60 develops...

    Correct

    • A patient with type 1 diabetes mellitus at the age of 60 develops urinary microalbuminuria (urinary albumin : creatinine ratio > 2.5 mg/mmol for men and > 3.5 mg/mmol for women).
      Which of the following options is likely to confer the most benefit in terms of prognosis?

      Your Answer: Reduce blood pressure to 130/80 mmHg or less using angiotensin converting enzyme(ACE)inhibitors

      Explanation:

      Microalbuminuria in Diabetes Mellitus

      Microalbuminuria is a common occurrence in both type 1 and type 2 diabetes mellitus. It is caused by damage to the renal basement membranes, which allows excess protein to leak into the affected nephrons. In type 1 diabetes, microalbuminuria is a prognostic indicator of chronic kidney disease, while in type 2 diabetes, it is associated with ischaemic heart disease.

      To improve outcomes, it is crucial to aggressively control blood pressure, which is more important than other factors such as HbA1c control. However, HbA1c control should not be ignored. Angiotensin-converting enzyme inhibitors are particularly helpful in controlling blood pressure and can even reverse microalbuminuria in affected patients. Therefore, it is essential to monitor and manage microalbuminuria in patients with diabetes mellitus to prevent further complications.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 5 - A 60-year-old man presents with unprovoked, painless, macroscopic haematuria. Dipstick testing confirms the...

    Correct

    • A 60-year-old man presents with unprovoked, painless, macroscopic haematuria. Dipstick testing confirms the presence of blood but no leukocytes or nitrites.
      Select the most likely cause of these symptoms.

      Your Answer: Bladder tumour

      Explanation:

      Understanding the Causes of Macroscopic Haematuria by Age

      Macroscopic haematuria, or visible blood in the urine, can be a concerning symptom that may indicate a serious underlying condition. The causes of macroscopic haematuria can vary depending on the age and gender of the patient. In general, painless macroscopic haematuria in an adult should be considered a potential sign of renal tract cancer until proven otherwise.

      For patients under 20 years old, glomerulopathies (especially IgA nephropathy), thin basement membrane disease, urinary infection, congenital malformation, hereditary nephritis (Alport’s Syndrome), and sickle cell disease are the most likely causes.

      For patients between 20 and 60 years old, urinary infection, nephrolithiasis, endometriosis, bladder, prostate, and renal cancers are the most common causes. The risk of cancer increases significantly after the age of 35-50.

      For patients over 60 years old, the most likely causes of macroscopic haematuria differ by gender. In males, cancer and prostatitis are the most common causes, while in females, cancer and urinary infection are the most common causes.

      It is important to note that while these age-related trends can be helpful in guiding diagnostic testing and treatment, almost any disease can affect anyone at any age. Therefore, a thorough evaluation by a healthcare professional is necessary to determine the underlying cause of macroscopic haematuria.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 6 - You assess a 55-year-old man who has stage 4 chronic kidney disease. Which...

    Incorrect

    • You assess a 55-year-old man who has stage 4 chronic kidney disease. Which medication can be safely prescribed considering his level of renal dysfunction?

      Your Answer: Nitrofurantoin

      Correct Answer: Warfarin

      Explanation:

      Severe renal failure patients should steer clear of tetracycline, metformin, nitrofurantoin, and lithium. However, warfarin may be well-tolerated, but patients may need more frequent monitoring.

      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.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 7 - A 50-year-old man has developed increasingly swollen legs over the previous month. He...

    Incorrect

    • A 50-year-old man has developed increasingly swollen legs over the previous month. He has been lethargic and anorexic. He describes his urine is frothy. Dipstick testing of urine reveals a trace of blood but is strongly positive for protein. His blood pressure is 140/85. There are no other abnormal physical signs. He takes no medication apart from ibuprofen for intermittent backache.
      Select the single most likely cause for this.

      Your Answer: Acute tubular necrosis

      Correct Answer: Membranous glomerulonephritis

      Explanation:

      Understanding Nephrotic Syndrome: Causes and Mechanisms

      Nephrotic syndrome is a condition characterized by proteinuria, hypoalbuminemia, edema, and hyperlipidemia. The primary causes of nephrotic syndrome include minimal-change nephropathy, focal glomerulosclerosis, and membranous nephropathy, while secondary causes include systemic diseases and drugs. Membranous glomerulonephritis is the most common cause of nephrotic syndrome in adults.

      The glomerular structural changes that may cause proteinuria involve damage to the endothelial surface, the glomerular basement membrane, or the podocytes. In membranous glomerulonephritis, immune complexes localize between the outer aspects of the basement membrane and the podocytes.

      If left untreated, nephrotic syndrome can progress to end-stage renal failure in 30-50% of patients. However, some patients with idiopathic membranous nephropathy may experience complete or partial spontaneous remission of nephrotic syndrome with stable renal function.

      It is important to differentiate nephrotic syndrome from other kidney conditions such as diffuse proliferative glomerulonephritis, IgA nephropathy, acute tubular necrosis, and acute interstitial nephritis. Understanding the causes and mechanisms of nephrotic syndrome can aid in proper diagnosis and treatment.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 8 - A 65-year-old woman with longstanding rheumatoid arthritis presents with fatigue and loss of...

    Correct

    • A 65-year-old woman with longstanding rheumatoid arthritis presents with fatigue and loss of appetite of recent origin. Her serum creatinine is 230 µmol/l (50-120 µmol/l) and urea is 13.5 mmol/l (2.5-6.5 mmol/l). She has taken diclofenac for pain relief for several years.
      Select from the list the single correct statement about this side-effect of diclofenac.

      Your Answer: It is likely to be reversible if the drug is stopped

      Explanation:

      The Renal Risks of NSAIDs

      One of the most common renal problems is sodium retention, which leads to water retention and oedema. This issue is particularly concerning for patients with pre-existing heart failure, as it can worsen their condition. Additionally, nonsteroidal anti-inflammatory drugs (NSAIDs) can cause hyperkalaemia by inhibiting aldosterone, especially in patients with diabetes, heart failure, or multiple myeloma. If the patient is taking potassium-sparing diuretics or ACE inhibitors, the hyperkalaemia may be more severe.

      NSAIDs can cause two types of acute renal failure. The first is haemodynamically mediated, where inhibition of prostaglandin synthesis can lead to reversible renal ischemia, a fall in GFR, and acute renal failure. The second is direct toxic effects on the kidney, such as acute tubular necrosis and acute interstitial nephritis. Adverse renal effects are generally reversible upon discontinuation of NSAID treatment. Glomerulosclerosis, typically caused by diabetes, can also be caused by drug-induced glomerular disease, including that caused by NSAIDs.

      High-dose NSAID use may significantly increase the risk of accelerated renal function decline in patients with chronic kidney disease. Therefore, caution should always be exercised when using NSAIDs, and they should be given at the lowest effective dose.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 9 - A 64-year-old man comes to your clinic. He has a medical history of...

    Correct

    • A 64-year-old man comes to your clinic. He has a medical history of hypertension and atrial fibrillation and is currently taking warfarin as an anticoagulant. During a routine hypertension clinic appointment 10 weeks ago, a urine dipstick showed the presence of blood and leucocytes. However, the initial urine microscopy and culture did not reveal any growth. The urine dipstick has been repeated twice since then, with the same result.

      What would be the best course of action in this situation?

      Your Answer: Refer to urology

      Explanation:

      Patients taking warfarin have a comparable incidence of non-visible haematuria to the general population, and thus should be evaluated in the same manner. While most haematuria protocols recommend referring younger patients (under 40 years) to nephrology, this patient’s age warrants referral to urology for a cystoscopy.

      Haematuria: Causes and Management

      The management of haematuria can be challenging due to the lack of widely followed guidelines. Haematuria is now classified as 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 urinary tract infections, menstruation, vigorous exercise, or sexual intercourse. Persistent non-visible haematuria may be caused by cancer, stones, benign prostatic hyperplasia, prostatitis, urethritis, or renal conditions such as IgA nephropathy or thin basement membrane disease. Spurious causes of haematuria include certain foods and drugs.

      Screening for haematuria is not recommended, and patients taking aspirin or warfarin should also 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 or protein:creatinine ratio, and blood pressure should also be checked. NICE guidelines recommend urgent referral for patients aged 45 or older with unexplained visible haematuria or visible haematuria that persists or recurs after successful treatment of urinary tract infection. Patients aged 60 or older with unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test should also be urgently referred. Patients under 40 years of age with normal renal function, no proteinuria, and who are normotensive may be managed in primary care.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 10 - A 57-year-old woman who has been receiving regular haemodialysis at the local General...

    Incorrect

    • A 57-year-old woman who has been receiving regular haemodialysis at the local General Hospital dies suddenly. On reviewing her regular medications, you note that she was taking aspirin, a statin and three antihypertensive agents. She had also been receiving erythropoietin injections.
      What is the most likely cause of sudden death in this patient?

      Your Answer: Pulmonary embolus (PE)

      Correct Answer: Cardiovascular disease

      Explanation:

      Common Causes of Sudden Death in Patients Undergoing Renal Dialysis

      Patients undergoing renal dialysis are at a high risk of cardiovascular disease, which is the leading cause of death in this population. Chronic renal failure leads to several risk factors, such as abnormal lipid levels and hypertension, that contribute to the development of cardiovascular disease. Statins and antihypertensive medications are commonly prescribed to manage these risk factors. Aspirin may also be prescribed to prevent vascular events, although it increases the risk of gastrointestinal bleeding.

      Although patients on dialysis are also at an increased risk of malignancies and pulmonary embolism, sudden death due to these causes is less common than sudden death due to cardiovascular failure. Occult malignancy and overwhelming sepsis are usually preceded by symptoms of illness, whereas sudden death is unexpected. Pulmonary embolism may occur in patients with multiple risk factors, but cardiovascular disease is a more likely cause of death in this context.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 11 - A 52-year-old man goes for a routine medical check-up before starting a new...

    Correct

    • A 52-year-old man goes for a routine medical check-up before starting a new job. He has no complaints, and his physical examination is unremarkable. Blood tests are ordered, and all the results are normal except for:

      Uric acid 0.66 mmol/l (0.18-0.48 mmol/l)

      After reading about gout online, the patient is concerned about his risk. What treatment should be started based on this finding?

      Your Answer: No treatment

      Explanation:

      NICE doesn’t recommend treating asymptomatic hyperuricaemia to prevent gout. While high levels of serum uric acid are associated with gout, it is possible to have hyperuricaemia without experiencing any symptoms. Primary prevention of gout in such cases has been found to be neither cost-effective nor beneficial to patients. Instead, lifestyle changes such as reducing consumption of red meat, alcohol, and sugar can help lower uric acid levels without the need for medication. The other options listed are only indicated for the treatment of gout when symptoms are present.

      Understanding Hyperuricaemia

      Hyperuricaemia is a condition characterized by elevated levels of uric acid in the blood. This can be caused by an increase in cell turnover or a decrease in the excretion of uric acid by the kidneys. While some individuals with hyperuricaemia may not experience any symptoms, it can be associated with other health conditions such as hyperlipidaemia, hypertension, and the metabolic syndrome.

      There are several factors that can contribute to the development of hyperuricaemia. Increased synthesis of uric acid can occur in conditions such as Lesch-Nyhan disease, myeloproliferative disorders, and with a diet rich in purines. On the other hand, decreased excretion of uric acid can be caused by drugs like low-dose aspirin, diuretics, and pyrazinamide, as well as pre-eclampsia, alcohol consumption, renal failure, and lead exposure.

      It is important to understand the underlying causes of hyperuricaemia in order to properly manage and treat the condition. Regular monitoring of uric acid levels and addressing any contributing factors can help prevent complications such as gout and kidney stones.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 12 - A 32-year-old man comes to the emergency surgery complaining of abdominal pain that...

    Incorrect

    • A 32-year-old man comes to the emergency surgery complaining of abdominal pain that started earlier in the day and is gradually worsening. The pain is situated on his left flank and extends down to his groin. He has no history of similar pain and is generally healthy. Upon examination, the man appears flushed and sweaty, but there are no other notable findings. What is the most appropriate initial course of action?

      Your Answer: Oral ciprofloxacin

      Correct Answer: IM diclofenac 75 mg

      Explanation:

      Management and Prevention of Renal Stones

      Renal stones, also known as kidney stones, can cause severe pain and discomfort. The British Association of Urological Surgeons (BAUS) has published guidelines on the management of acute ureteric/renal colic. Initial management includes the use of NSAIDs as the analgesia of choice for renal colic, with caution taken when prescribing certain NSAIDs due to increased risk of cardiovascular events. Alpha-adrenergic blockers are no longer routinely recommended, but may be beneficial for patients amenable to conservative management. Initial investigations include urine dipstick and culture, serum creatinine and electrolytes, FBC/CRP, and calcium/urate levels. Non-contrast CT KUB is now recommended as the first-line imaging for all patients, with ultrasound having a limited role.

      Most renal stones measuring less than 5 mm in maximum diameter will pass spontaneously within 4 weeks. However, more intensive and urgent treatment is indicated in the presence of ureteric obstruction, renal developmental abnormality, and previous renal transplant. Treatment options include lithotripsy, nephrolithotomy, ureteroscopy, and open surgery. Shockwave lithotripsy involves generating a shock wave externally to the patient, while ureteroscopy involves passing a ureteroscope retrograde through the ureter and into the renal pelvis. Percutaneous nephrolithotomy involves gaining access to the renal collecting system and performing intra corporeal lithotripsy or stone fragmentation. The preferred treatment option depends on the size and complexity of the stone.

      Prevention of renal stones involves lifestyle modifications such as high fluid intake, low animal protein and salt diet, and thiazide diuretics to increase distal tubular calcium resorption. Calcium stones may also be due to hypercalciuria, which can be managed with thiazide diuretics. Oxalate stones can be managed with cholestyramine and pyridoxine, while uric acid stones can be managed with allopurinol and urinary alkalinization with oral bicarbonate.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 13 - A 65-year-old man with symptoms of prostatism has a serum prostate specific antigen...

    Correct

    • A 65-year-old man with symptoms of prostatism has a serum prostate specific antigen (PSA) concentration of 20 µg/l (normal < 4 µg/l).
      Select from the list which single correct statement about the clinical importance of this result is the most likely.

      Your Answer: It is more likely to reflect prostatic cancer than benign prostatic hypertrophy

      Explanation:

      Understanding Prostate-Specific Antigen (PSA)

      Prostate-specific antigen (PSA) is a protein produced by the prostate gland that plays a crucial role in male reproductive function. Its primary function is to liquefy semen, allowing sperm to move freely. PSA is also believed to help dissolve cervical mucous, facilitating the entry of sperm into the uterus.

      While PSA is present in small amounts in the blood of men with healthy prostates, elevated levels can indicate the presence of prostate cancer or other prostate disorders. However, PSA is not specific to cancer and a biopsy is needed to confirm a diagnosis.

      PSA levels increase with age and in benign prostatic hypertrophy and prostatitis, but a high concentration is more likely to be due to cancer than benign disease. It is important to note that PSA levels may also increase slightly after a digital rectal examination or ejaculation.

      Understanding PSA and its role in prostate health is crucial for early detection and treatment of prostate cancer. Regular prostate exams and PSA screenings are recommended for men over the age of 50, or earlier for those with a family history of prostate cancer.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 14 - A 50-year-old man has renal impairment. His eGFR has been measured at 32...

    Correct

    • A 50-year-old man has renal impairment. His eGFR has been measured at 32 ml/min/1.73 m2. He has developed anaemia. He has a normocytic anaemia with a haemoglobin concentration of 98 g/l (normal 130 – 180g/l). His ferritin level is low.
      Select from the list the single correct option concerning anaemia in chronic kidney disease.

      Your Answer: Treatment of his anaemia should aim to maintain his haemoglobin between 100g/l and 120g/l

      Explanation:

      Managing Anaemia in Chronic Kidney Disease Patients

      Anaemia is a common occurrence in patients with severe renal impairment. The kidneys’ reduced ability to produce erythropoietin leads to normochromic, normocytic anaemia. The National Institute for Health and Care Excellence (NICE) recommends investigating and managing anaemia in patients with chronic kidney disease (CKD) if their haemoglobin level falls to 110g/l or less (105g/l if less than 2 years) or if they develop symptoms of anaemia.

      Iron deficiency is a common issue in people with CKD, which may be due to poor dietary intake, occult bleeding, or functional imbalance between the iron requirements of the erythroid marrow and the actual iron supply. It is important to manage iron deficiency before starting erythropoetic stimulating agent therapy. The aspirational haemoglobin range is typically between 100 and 120g/l (95 to 115g/l if less than 2 years to reflect lower normal range in that age group).

      It is not recommended to prescribe vitamin C supplements as adjuvants specifically for the anaemia of CKD. Overall, managing anaemia in CKD patients requires careful attention to iron levels and haemoglobin ranges.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 15 - A 58-year-old woman with diet-controlled type II diabetes is being treated with a...

    Incorrect

    • 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 angiotensin–converting enzyme inhibitor

      Correct 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.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 16 - A couple is struggling with infertility. The male partner is 32-years-old and the...

    Incorrect

    • A couple is struggling with infertility. The male partner is 32-years-old and the female partner is 34-years-old. They have no children and she has never been pregnant before. They have been having unprotected sexual intercourse regularly for the past 14 months. Prior to this, they used condoms and she has not used any form of hormonal contraception for over two years.

      Upon further discussion, the male partner had a unilateral orchidopexy at the age of 5 for an undescended testicle. He is in good health, doesn't smoke, and has a body mass index of 24.8 kg/m2. The female partner has regular periods every four weeks and experiences bleeding for three to four days with each period. She doesn't have significant menorrhagia or dysmenorrhea and denies any unscheduled vaginal bleeding or discharge. Her periods have been light and regular for as long as she can remember. She has no significant medical history and is a non-smoker with a body mass index of 23.4 kg/m2.

      What is the most appropriate advice to provide for management at this stage?

      Your Answer: He should be referred to an urologist

      Correct Answer: They should continue to have regular unprotected sexual intercourse and return for review if they have not conceived within 2 years

      Explanation:

      Investigating Infertility in Couples

      When a couple has been having regular unprotected sexual intercourse for a year without any comorbidities affecting fertility, it is important to investigate infertility. However, if the woman is 36 years or older, or there is a known cause or risk factor for infertility, immediate referral is necessary. Couples with male factor problems, tubal disorders, or ovulatory disorders should also be referred if primary care treatment is not possible. Additionally, patients with unexplained infertility after two years of regular unprotected sexual intercourse should be referred.

      In cases where there is a history of undescended testes, there is a potential male factor problem that requires immediate investigation. While the woman’s history doesn’t suggest any specific problem, semen analysis for the male is the best initial investigation approach. Proper investigation and referral can help couples receive the necessary treatment and support to overcome infertility.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 17 - A 63-year-old lady presents to your clinic with complaints of urine leakage when...

    Correct

    • A 63-year-old lady presents to your clinic with complaints of urine leakage when she sneezes and coughs. She denies dysuria but reports seeing blood in her urine. She has no gastrointestinal symptoms. On physical examination, her abdomen is soft and non-tender. Urinalysis reveals the presence of blood, and an MSU shows RBC>100/mm3. She has no known allergies. What would be your approach to managing this patient?

      Your Answer: Refer urgently to urology

      Explanation:

      Managing Urinary Incontinence and Haematuria in Women

      Stress urinary incontinence can be managed through lifestyle changes such as fluid and caffeine intake reduction, and pelvic floor muscle training. If medical or surgical treatment is preferred, duloxetine can be used as a second-line option. However, trimethoprim is not appropriate in the absence of urinary infection. Routine referral to urology may be necessary for surgical management, but only if there are no red flags.

      On the other hand, nephrology referral is indicated for women under 50 years old with microscopic haematuria, proteinuria, or decreased eGFR. In this case, an urgent urology referral is necessary due to the patient’s macroscopic haematuria without urinary tract infection and unexplained microscopic haematuria at her age.

      Managing urinary incontinence and haematuria in women requires careful consideration of the patient’s symptoms and medical history. Proper diagnosis and referral to the appropriate specialist can help ensure effective treatment and management of these conditions.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 18 - A 28-year-old woman visits her GP at 37 weeks of pregnancy complaining of...

    Correct

    • A 28-year-old woman visits her GP at 37 weeks of pregnancy complaining of urinary frequency and urgency. She reports feeling generally well, with good fetal movements and no vaginal bleeding. Her vital signs are within normal limits, with a temperature of 37.4ºC, heart rate of 85 bpm, respiratory rate of 18/min, and blood pressure of 120/75 mmHg.

      Upon performing a urine dipstick test, leukocytes are detected while nitrites, blood, and ketones are absent.

      What is the most appropriate course of action?

      Your Answer: Treat with seven days of amoxicillin

      Explanation:

      For a pregnant woman in the third trimester with a UTI, the recommended antibiotic treatment is amoxicillin for seven days. Nitrofurantoin is the first-line antibiotic, but it should be avoided later in pregnancy due to potential harm to the baby. Cefalexin is also an appropriate second-line option. It is important to obtain a urine sample for testing before starting treatment and to confirm cure with a follow-up test. Hospital admission is not necessary unless there are signs of sepsis or pyelonephritis or pregnancy complications. Empirical therapy should be initiated promptly, and treatment can be adjusted based on sensitivity results if necessary.

      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.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 19 - A 45-year-old man presents with a 3-day history of a progressively diminishing urinary...

    Incorrect

    • A 45-year-old man presents with a 3-day history of a progressively diminishing urinary stream, dysuria and urinary frequency. He denies any possibility of a sexually transmitted disease. He feels quite unwell. On examination, he has temperature of 38.7°C and digital rectal examination (DRE) reveals a very tender and slightly enlarged prostate.
      What is the most likely diagnosis?

      Your Answer: Prostatic abscess

      Correct Answer: Acute prostatitis

      Explanation:

      Differential Diagnosis for Dysuria and a Tender Prostate on DRE in Men

      When a man presents with dysuria and a tender prostate on digital rectal examination (DRE), several conditions may be considered. Acute prostatitis is a likely diagnosis, especially if the patient also has lower urinary tract symptoms and fever. The cause is often a urinary tract infection, with Escherichia coli being the most common culprit. In sexually active men under 35, Neisseria gonorrhoeae should also be considered.

      Prostate cancer is less likely to present with acute symptoms and is more commonly associated with a gradual onset of symptoms or urinary retention. Cystitis is rare in men and would not explain the tender prostate on examination. Urethritis may cause dysuria and urinary frequency but is not typically associated with a tender prostate on DRE. Prostatic abscess should be suspected if symptoms worsen despite treatment for acute bacterial prostatitis or if a fluctuant mass is palpable in the prostate gland.

      In summary, when a man presents with dysuria and a tender prostate on DRE, acute prostatitis is the most likely diagnosis, but other conditions should also be considered based on the patient’s history and clinical presentation.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 20 - A 75-year-old man with Parkinson’s disease has a serum creatinine of 746 μmol/l...

    Correct

    • A 75-year-old man with Parkinson’s disease has a serum creatinine of 746 μmol/l (60-120 μmol/l). He was known to have normal renal function two years previously. On examination, he has evidence of rigidity, resting tremor and postural instability. He appears to have bilateral small pupils. He has a postural BP drop from 160/72 mm/Hg when supine to 138/60 mmHg when standing. Ultrasound shows bilateral hydronephrosis and a full bladder.
      Which of the following is the most likely cause of obstructive renal failure in this patient?

      Your Answer: Neurogenic bladder

      Explanation:

      Neurogenic Bladder and Other Causes of Obstructive Renal Failure in Parkinson’s Disease

      Parkinson’s disease is often associated with autonomic dysfunction, which can lead to bladder problems such as urgency, frequency, nocturia, and incontinence. In some cases, these symptoms may be mistaken for benign prostatic hypertrophy, but it is important to consider the possibility of neurogenic bladder when risk factors are present. Multichannel urodynamic studies can help confirm the diagnosis and prevent complications such as post-prostatectomy incontinence. Other potential causes of obstructive renal failure in Parkinson’s disease include retroperitoneal fibrosis and renal papillary necrosis, which are rare but serious conditions that require prompt diagnosis and treatment.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 21 - A 70-year-old man with newly diagnosed prostate cancer is undergoing androgen deprivation therapy....

    Incorrect

    • A 70-year-old man with newly diagnosed prostate cancer is undergoing androgen deprivation therapy. He has no other significant medical history and is not taking any other medications.

      How should his bone density be managed in light of this treatment?

      Your Answer: Start bisphosphonate treatment

      Correct Answer: Formally assess his fracture risk to determine the need for further investigation and treatment for osteoporosis

      Explanation:

      Managing Osteoporosis Risk in Men with Prostate Cancer

      Osteoporosis is a potential risk for men undergoing hormonal androgen deprivation therapy for prostate cancer. While bisphosphonates are not routinely recommended, assessing fracture risk can guide the need for investigation and treatment. Bisphosphonates may be offered to men with confirmed osteoporosis, while denosumab can be used if bisphosphonates are not an option. However, a confirmed diagnosis of osteoporosis is necessary before treatment can be prescribed. Lifestyle advice is important, but it is not a substitute for fracture risk assessment and further investigation, such as a DEXA scan, may be necessary. By managing osteoporosis risk, men with prostate cancer can reduce the likelihood of fractures and maintain their quality of life.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 22 - A 55-year-old man who is taking lithium for bipolar disorder comes in for...

    Incorrect

    • A 55-year-old man who is taking lithium for bipolar disorder comes in for a check-up. Upon routine examination, he is discovered to have hypertension with a blood pressure of 166/82 mmHg, which is confirmed by two separate readings. His urine dipstick is negative and his renal function is normal. What medication would be the most suitable to initiate?

      Your Answer: Bendroflumethiazide

      Correct Answer: Amlodipine

      Explanation:

      Lithium toxicity may be caused by diuretics, ACE-inhibitors, and angiotensin II receptor antagonists. According to the BNF, the combination of lithium with diltiazem or verapamil may increase the risk of neurotoxicity, but there is no significant interaction with amlodipine. Although alpha-blockers are not known to interact with lithium, they are not recommended as the first-line treatment for hypertension. The NICE guidelines for hypertension suggest that amlodipine could be a suitable initial option, even if the patient is taking lithium.

      Lithium is a drug used to stabilize mood in patients with bipolar disorder and refractory depression. It has a narrow therapeutic range of 0.4-1.0 mmol/L and is primarily excreted by the kidneys. Lithium toxicity occurs when the concentration exceeds 1.5 mmol/L, which can be caused by dehydration, renal failure, and certain drugs such as diuretics, ACE inhibitors, NSAIDs, and metronidazole. Symptoms of toxicity include coarse tremors, hyperreflexia, acute confusion, polyuria, seizures, and coma.

      To manage mild to moderate toxicity, volume resuscitation with normal saline may be effective. Severe toxicity may require hemodialysis. Sodium bicarbonate may also be used to increase the alkalinity of the urine and promote lithium excretion, but there is limited evidence to support its use. It is important to monitor lithium levels closely and adjust the dosage accordingly to prevent toxicity.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 23 - A 25-year-old female patient visits the GP clinic complaining of dysuria, visible haematuria,...

    Incorrect

    • A 25-year-old female patient visits the GP clinic complaining of dysuria, visible haematuria, and feeling generally unwell for the past 24 hours. She also has a fever. The patient has no medical history and is not taking any regular medications. During the examination, the patient's abdomen is soft with slight suprapubic tenderness. There is no renal angle tenderness, and bowel sounds are normal.

      What is the appropriate course of action for management?

      Your Answer: Urine dip and oral antibiotics

      Correct Answer: Oral antibiotics and mid-stream urine (MSU)

      Explanation:

      For women with suspected UTI accompanied by visible or non-visible haematuria, it is necessary to send an MSU along with oral antibiotics. Admission for suspected pyelonephritis is not required, but safety netting should be done. Encouraging hydration and reviewing in 24-48h is not appropriate for this case. Oral antibiotics without any investigations are not recommended. An MSU is essential in the presence of haematuria. Delaying antibiotics could lead to pyelonephritis, so a delayed prescription could be considered for less unwell patients.

      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.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 24 - A 45-year-old man with no previous medical history of note attends for a...

    Incorrect

    • 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: Acute kidney injury

      Correct 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.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 25 - A 50-year-old woman comes to the clinic complaining of urinary incontinence. She reports...

    Incorrect

    • A 50-year-old woman comes to the clinic complaining of urinary incontinence. She reports frequent urine leakage and a strong urge to urinate that she cannot control. She denies experiencing dysuria or hematuria and has no gastrointestinal symptoms. Physical examination reveals a soft, non-tender abdomen, and urinalysis is normal. The patient drinks seven glasses of water per day and avoids caffeinated beverages. She has a BMI of 20.2 and is a non-smoker. If non-pharmacological interventions fail, what is the first-line medication for her condition?

      Your Answer: Duloxetine

      Correct Answer: Furosemide

      Explanation:

      Treatment options for Urinary Urge Incontinence

      Urinary urge incontinence is a common condition that can be treated with supervised bladder training for at least six weeks. This training can be provided by a continence nurse, physiotherapist, or urology clinic. If symptoms persist, an Antimuscarinic drug can be prescribed, with the lowest effective dose used and titrated upwards if necessary. It may take up to four weeks for the drug to take effect, and side effects such as dry mouth and constipation may occur. First-line drugs include oxybutynin, tolterodine, and darifenacin.

      It is important to note that diuretics such as furosemide can potentially worsen symptoms of urinary urge incontinence. Amitriptyline is not recommended for this condition, as it is primarily used for depression, neuropathic pain, and migraine prophylaxis. Duloxetine may be used as a second-line treatment for stress incontinence, but it is not included in NICE guidelines for urinary urge incontinence. Desmopressin is typically used for other conditions such as diabetes insipidus, multiple sclerosis, enuresis, and bleeding disorders.

      In summary, supervised bladder training and Antimuscarinic drugs are effective treatment options for urinary urge incontinence. It is important to consult with a healthcare professional to determine the best course of treatment for individual cases.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 26 - A 42-year-old woman visits her General Practitioner complaining of fever, dysuria, suprapubic pain,...

    Incorrect

    • A 42-year-old woman visits her General Practitioner complaining of fever, dysuria, suprapubic pain, and increased frequency of micturition. This is happening 14 days after finishing antibiotic treatment for an Escherichia coli (E coli) urinary-tract infection (UTI). She is currently using condoms for contraception. Urine culture reveals the presence of the same E coli. She has no history of recurrent UTIs and is in good health otherwise.
      What is the most likely cause of her persistent symptoms?

      Your Answer: Interstitial cystitis

      Correct Answer: Silent pyelonephritis

      Explanation:

      Differential diagnosis of recurrent UTI in a young woman

      Recurrent urinary tract infections (UTIs) are a common problem in women, but their underlying causes can vary. In this case, the patient presents with symptoms suggestive of cystitis, but her urine culture is positive for the same organism despite completing a course of antibiotics. This raises the possibility of silent pyelonephritis, a condition in which the kidney is infected but there are no overt signs of inflammation. Other potential diagnoses to consider include interstitial cystitis, atrophic vaginitis, chlamydial urethritis, and use of spermicidal jelly. Each of these conditions has distinct features that can help guide further evaluation and management. For example, interstitial cystitis is characterized by sterile urine cultures and chronic pelvic pain, while atrophic vaginitis is more common in postmenopausal women and can cause recurrent UTIs due to changes in vaginal flora. Chlamydial urethritis may be suspected if there is a history of unprotected sexual activity, and a mid-stream urine culture would be negative. Finally, the use of spermicidal jelly can increase the risk of UTIs, but this is usually due to re-infection rather than relapse. Overall, a careful history and physical examination, along with appropriate laboratory tests, can help narrow down the differential diagnosis and guide appropriate treatment.

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      • Kidney And Urology
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  • Question 27 - A 55-year-old man with no significant medical history asks for a PSA test...

    Correct

    • A 55-year-old man with no significant medical history asks for a PSA test after hearing about a friend of his father who was diagnosed with prostate cancer. What should be done in this situation?

      Your Answer: Give him a patient information leaflet with details of the PSA test and allow him to make the choice

      Explanation:

      PSA Testing for Prostate Cancer

      Prostate specific antigen (PSA) is an enzyme produced by the prostate gland, and it is used as a tumour marker for prostate cancer. However, there is still much debate about its usefulness as a screening tool. The NHS Prostate Cancer Risk Management Programme (PCRMP) has published guidelines on how to handle requests for PSA testing in asymptomatic men. The National Screening Committee has decided not to introduce a prostate cancer screening programme yet, but rather allow men to make an informed choice.

      The PCRMP has recommended age-adjusted upper limits for PSA, while NICE Clinical Knowledge Summaries suggest a lower threshold for referral. However, PSA levels may also be raised by other conditions such as benign prostatic hyperplasia, prostatitis, urinary tract infection, ejaculation, vigorous exercise, urinary retention, and instrumentation of the urinary tract.

      PSA testing has poor specificity and sensitivity, and various methods are used to try and add greater meaning to a PSA level, including age-adjusted upper limits and monitoring change in PSA level with time. It is important to note that digital rectal examination may or may not cause a rise in PSA levels, which is a matter of debate.

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      • Kidney And Urology
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  • Question 28 - A 67-year-old man who has type II diabetes attends his general practice surgery...

    Incorrect

    • A 67-year-old man who has type II diabetes attends his general practice surgery for his annual review. He takes metformin and gliclazide.
      On examination, his blood pressure (BP) is 130/80 mmHg. There are no signs of retinopathy. He feels well.
      Investigations:
      Investigation Result Normal values
      Haemoglobin A1c (HbA1c) 53 mmol/mol < 43 mmol/mol
      Estimated glomerular filtration rate (eGFR) 55 ml/min per 1.73 m2 > 90 ml/min per 1.73 m2
      Albumin : creatinine ratio (ACR) 5.4 mg/mmol (up from 3.0 mg/mmol three months ago) < 1.0 mg/mmol
      What is the most appropriate initial management option for this patient?

      Your Answer: Optimise his diabetic control and repeat the test in six months

      Correct Answer: Start an angiotensin-converting enzyme (ACE) inhibitor

      Explanation:

      Managing Chronic Kidney Disease in a Patient with Diabetes: Treatment Options

      Chronic kidney disease (CKD) is a common complication of diabetes, and early management is crucial to slow progression. In a patient with diabetic nephropathy and stage 3a CKD, the following treatment options are available:

      1. Start an angiotensin-converting enzyme (ACE) inhibitor: This is the most appropriate first-line treatment to reduce the risk of all-cause mortality in patients with diabetic kidney disease.

      2. Refer him to a Nephrologist: Management of CKD requires specialized care to slow progression.

      3. Optimise his diabetic control and repeat the test in six months: While important, diabetic control should not be the focus of immediate management in this patient.

      4. Start a direct renin inhibitor: This treatment is not a priority as the patient’s blood pressure is already below the target.

      5. Start a low-protein diet and repeat urinalysis in six months: Dietary protein restriction is not recommended in early-stage CKD, but high-protein intake should be avoided in stage 4 CKD under the guidance of a dietitian.

      In conclusion, early management of CKD in patients with diabetes is crucial to slow progression and reduce the risk of mortality. Treatment options should be tailored to the individual patient’s needs and managed by a specialist.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 29 - A 57-year-old man with a history of stage 3a chronic kidney disease and...

    Correct

    • A 57-year-old man with a history of stage 3a chronic kidney disease and hypertension presents with recurrent gout. He has experienced three episodes in the past year and requires prophylactic therapy with allopurinol. He is currently taking amlodipine and atorvastatin. What is the recommended approach for initiating allopurinol in this patient?

      Your Answer: Commence allopurinol and provide colchicine to take simultaneously while starting

      Explanation:

      When starting allopurinol for this patient, it is important to use either NSAID or colchicine cover. This is because allopurinol can cause acute flares of gout due to changes in uric acid levels in the serum and tissues. Therefore, commencing allopurinol without any cover is not recommended. However, since the patient has chronic kidney disease, non-steroidal anti-inflammatories should be avoided. Indomethacin may be an alternative cover option for some patients. Prednisolone is effective but has many adverse effects and should only be used for a few days. It is important to note that this patient doesn’t have any contraindications to allopurinol, such as a history of hypersensitivity syndrome, Stevens-Johnson syndrome, toxic epidermal necrolysis, having the HLA-B*5801 allele, or severe renal failure.

      Gout is caused by chronic hyperuricaemia and is managed acutely with NSAIDs or colchicine. Urate-lowering therapy (ULT) is recommended for patients with >= 2 attacks in 12 months, tophi, renal disease, uric acid renal stones, or prophylaxis if on cytotoxics or diuretics. Allopurinol is first-line ULT, with a delayed start recommended until inflammation has settled. Lifestyle modifications include reducing alcohol intake, losing weight if obese, and avoiding high-purine foods. Other options for refractory cases include febuxostat, uricase, and pegloticase.

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      • Kidney And Urology
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  • Question 30 - A 60-year-old man comes to see you to discuss PSA testing. He plays...

    Correct

    • A 60-year-old man comes to see you to discuss PSA testing. He plays tennis with a few friends once a week and they have all been talking about the PSA test after one of his friends went to see his own GP with 'waterworks' problems.

      He has no lower urinary tract symptoms and denies any history of haematuria or erectile dysfunction. He has one brother who is 63 and his father is still alive aged 86. There is no family history of prostate cancer. He is currently well.

      He is very keen to have a PSA blood test performed.

      What advice would you give to this patient?

      Your Answer: He should be advised of the benefits and limitations of PSA testing and make an individual decision on whether to have the test

      Explanation:

      PSA Testing in Asymptomatic Men

      PSA testing in asymptomatic men is a controversial issue, with some advocating for it as a screening test and others wary of overtreatment and patient harm. The limitations of PSA testing in terms of sensitivity and specificity are significant, with two out of three men with a raised PSA not having prostate cancer and 15 out of 100 with a negative PSA having prostate cancer. Additionally, PSA testing cannot distinguish between slow and fast-growing cancers.

      Currently, PSA testing is not recommended as a screening test for prostate cancer in men of any age. However, in men with lower urinary tract symptoms, haematuria, or erectile dysfunction, digital rectal examination (DRE) and PSA testing should be offered. Asymptomatic men with no family history of prostate cancer should be informed of the pros and cons of the test and allowed to make their own decision. DRE should also be offered, and advice given on the combined use of DRE and PSA testing to detect any prostate abnormalities.

      If a focal abnormality suggestive of cancer is found during DRE, this alone should prompt referral, and a PSA should be performed but would not alter the decision to refer. Similarly, an abnormal PSA with a normal DRE should also prompt referral. A normal DRE doesn’t mean that PSA testing is necessarily unwarranted.

      Family history is an important factor when considering prostate cancer. If the patient has a first-degree relative with prostate cancer, this may influence their decision on whether to have a PSA blood test. The risk of prostate cancer is increased by 112-140% for men with an affected father and 187-230% for men with an affected brother. Risks are higher for men under the age of 65 and for men where the relative is diagnosed before the age of 60.

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      • Kidney And Urology
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  • Question 31 - A 65-year-old woman presents with urinary frequency and dysuria for the last 3...

    Correct

    • A 65-year-old woman presents with urinary frequency and dysuria for the last 3 days. She denies vomiting or fevers and has no back pain. She has a history of osteoarthritis but no other significant medical conditions.

      During the examination, she experiences mild suprapubic tenderness, but there is no renal angle tenderness. Her heart rate is 68 beats per minute, blood pressure is 134/80 mmHg, and tympanic temperature is 36.8 oC. Urinalysis reveals 2+ leucocytes, positive nitrites, and no haematuria.

      Based on the current NICE guidelines, what is the most appropriate next step in management?

      Your Answer: Send a urine culture and commence a 3 day course of nitrofurantoin immediately

      Explanation:

      For women over 65 years old with suspected urinary tract infections, it is recommended to send an MSU for urine culture according to current NICE CKS guidance. Asymptomatic bacteriuria is common in older patients, so a urine dip is no longer recommended. However, a urine culture can help determine appropriate antibiotic therapy in this age group. Antibiotics should be prescribed for 3 days in women and 7 days in men with suspected urinary tract infections. Since the woman is experiencing symptoms, it is appropriate to administer antibiotics immediately rather than waiting for culture results.

      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 bacteriuria, 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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      • Kidney And Urology
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  • Question 32 - Which statement is accurate when analyzing a semen analysis report? ...

    Incorrect

    • Which statement is accurate when analyzing a semen analysis report?

      Your Answer: Motility below 70% is usually abnormal

      Correct Answer: 15% abnormal forms is within normal limits

      Explanation:

      Understanding Semen Analysis Results

      Semen analysis is a crucial test that helps determine male fertility. According to the World Health Organisation guidelines, a sperm sample showing 15% or more sperm of normal morphology is considered normal. It is recommended to abstain from masturbation and/or intercourse for at least two days before the test.

      Low volume is a common issue, often caused by missing the container. Motility below 40% is a cause for concern, and the pH should be between 7 and 8.5. The specimen should be examined within an hour, and a count below 20 million would be of some concern, while below 10 million would be clinically significant.

      When conducting semen analysis, the results should be compared with the WHO reference values. The semen volume should be 1.5 ml or more, pH should be 7.2 or more, sperm concentration should be 15 million spermatozoa per ml or more, and the total sperm number should be 39 million spermatozoa per ejaculate or more. The total motility should be 40% or more motile or 32% or more with progressive motility, vitality should be 58% or more, and live spermatozoa sperm morphology should be 4% or more.

      In conclusion, understanding semen analysis results is crucial in determining male fertility. It is important to follow the WHO guidelines and compare the results with the reference values to identify any potential issues.

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      • Kidney And Urology
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  • Question 33 - A 6-month-old boy was thought to have a unilateral undescended testicle at birth....

    Incorrect

    • 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: Review the surgical option after 12 months

      Correct 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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      • Kidney And Urology
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  • Question 34 - A 36-year-old man comes to the clinic with his partner seeking evaluation for...

    Incorrect

    • A 36-year-old man comes to the clinic with his partner seeking evaluation for infertility. He gives a specimen that shows azoospermia. He has a history of recurrent urinary tract infections.

      What is the most probable diagnosis?

      Your Answer: Partial retrograde ejaculation

      Correct Answer: Varicocoele

      Explanation:

      Retrograde Ejaculation as a Cause of Infertility

      Retrograde ejaculation is a condition that can lead to infertility in men. It may occur after surgery for benign prostatic hyperplasia or due to chronic urethral scarring caused by recurrent infections. In retrograde ejaculation, semen is redirected to the bladder instead of being expelled through the penis during ejaculation. This can make it difficult or impossible for sperm to reach the female reproductive system and fertilize an egg, leading to infertility. It is important to note that there are no other known causes of infertility in this case, based on the patient’s history and examination findings.

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      • Kidney And Urology
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  • Question 35 - A 60-year-old man has Parkinson's disease and is started on treatment. A month...

    Incorrect

    • A 60-year-old man has Parkinson's disease and is started on treatment. A month later he presents and is concerned that his urine is dark red in color.
      Select the most probable cause.

      Your Answer: Wilson's disease

      Correct Answer: L-Dopa treatment

      Explanation:

      Understanding Acute Interstitial Nephritis and its Causes

      Acute interstitial nephritis is a condition that results in acute kidney injury. The most common cause of this condition is a drug hypersensitivity reaction, accounting for 40-60% of cases. However, drugs used for Parkinson’s disease are not known to cause nephritis.

      Wilson’s disease, on the other hand, is a condition characterized by abnormal copper metabolism. It typically presents as liver disease in children and adolescents, and as neuropsychiatric illness in young adults, which may include Parkinsonian features. Although haematuria has been reported in Wilson’s disease, gross haematuria is uncommon in urinary tract infection.

      L-Dopa is the primary treatment for Parkinson’s disease, and it can cause reddish discolouration of urine and other body fluids. In contrast, bromocriptine doesn’t have this side effect. While the BNF reports that the side effect of bromocriptine is uncommon, it would still be wise to test the urine for blood.

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      • Kidney And Urology
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  • Question 36 - A previously healthy 8-year-old girl presents generally unwell, with reduced volumes of smoky-coloured...

    Correct

    • A previously healthy 8-year-old girl presents generally unwell, with reduced volumes of smoky-coloured urine. She had a sore throat two weeks previously. Immunisations up to date. There is no FH/SH of note. On examination her temperature is 37.6°C. She looks quiet and unwell, with slight periorbital oedema. Respiratory rate 15/min, pulse 90/min, blood pressure is 130/100 mmHg. Her JVP is elevated and she has tenderness in both loins. Urine dipstick show 3+ haematuria and 3+ proteinuria. Red cell casts are seen on urine microscopy. What is the most likely diagnosis?

      Your Answer: Post-streptococcal glomerulonephritis

      Explanation:

      Nephritis, also known as acute nephritic syndrome, is a condition characterized by haematuria, proteinuria, oliguria, and oedema with elevated blood pressure. In most cases, the preceding throat infection makes post-streptococcal glomerulonephritis the most likely cause. While blood tests such as ASOT may be useful in confirming the diagnosis, the clinical picture is usually clear.

      The severity of nephritis varies from transient asymptomatic haematuria to severe nephritis with acute renal and heart failure. Treatment is supportive, with close attention to fluid balance. Penicillin is often prescribed, but it may not influence the disease course or spread to family members. Fortunately, 95% of patients recover completely.

      In some cases, uraemia may accompany oliguria, but the clinical and dipstick findings are usually enough for a presumptive diagnosis. In children, the prognosis is excellent, with complete recovery in the vast majority of cases. Fewer than 1% of children experience elevated creatinine levels 10-15 years after an episode.

      Overall, understanding the symptoms, diagnosis, and treatment of nephritis is crucial for managing this condition effectively.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 37 - A 66-year-old man undergoes routine blood tests at his General Practice Surgery. These...

    Incorrect

    • A 66-year-old man undergoes routine blood tests at his General Practice Surgery. These reveal an estimated glomerular filtration rate (eGFR) of 64 ml/min (normal range: > 90 ml/min).
      A repeat test three months later gives an eGFR result of 62 ml/min. A urine albumin : creatinine ratio (ACR) is 2.5 mg/mmol (normal range: < 3 mg/mmol). He is otherwise well with no symptoms.
      What is the most appropriate interpretation of these results?

      Your Answer: Chronic kidney disease (CKD) stage 1

      Correct Answer: No CKD

      Explanation:

      Understanding eGFR Results and CKD Stages

      When interpreting eGFR results, it is important to consider other markers of kidney damage such as albuminuria. An eGFR of 60-89 ml/min is considered mild and not indicative of CKD in the absence of albuminuria.

      A sustained reduction in eGFR over three months is not indicative of acute kidney injury, which typically involves a sudden and drastic reduction in eGFR.

      CKD stage 1 is diagnosed when eGFR is >90 ml/min and there is proteinuria (urine ACR >3 mg/mmol). This patient’s eGFR result of 62 ml/min and ACR of 2.5 mg/mmol doesn’t meet these criteria.

      CKD stage 2 is diagnosed when eGFR is 60-89 ml/min and ACR is >3 mg/mmol. While the patient’s eGFR result fits this criteria, the sustained drop and normal ACR exclude this diagnosis.

      CKD stage 3a is diagnosed when eGFR is 45-59 ml/min with or without other markers of kidney damage. This patient doesn’t meet this diagnostic marker.

      In summary, understanding eGFR results and other markers of kidney damage is crucial in determining CKD stages.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 38 - A pair undergo examinations for sterility. What is the most suitable guidance to...

    Correct

    • A pair undergo examinations for sterility. What is the most suitable guidance to provide concerning sperm collection?

      Your Answer: Abstain for 3-5 days before giving sample + deliver sample to lab within 1 hour

      Explanation:

      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.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 39 - A 42-year-old man presents with painless left testicular enlargement. He reports noticing it...

    Correct

    • A 42-year-old man presents with painless left testicular enlargement. He reports noticing it approximately 3 weeks ago and denies any urinary symptoms or penile discharge.
      What is the most suitable plan of action?

      Your Answer: Refer to urology on a suspected cancer pathway

      Explanation:

      Urgent Referral Pathway for Suspected Testicular Cancer

      Any painless enlargement of the testis should be referred urgently to urology for investigation of testicular cancer. The patient should be seen within 2 weeks, and an ultrasound should be arranged urgently. While serum alpha-fetoprotein (AFP) is a tumour marker associated with testicular cancer, it should not be used alone to exclude a tumour. AFP can also be used in staging. A mid-stream specimen of urine (MSU) is not necessary unless there are urinary symptoms or signs of infection. Antibiotics are not indicated for painless swelling without signs of infection or epididymo-orchitis. While prompt investigation is necessary, urgent urological admission is not required unless the patient is acutely unwell.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 40 - A 30-year-old woman who is currently 8 weeks pregnant contacts the clinic to...

    Incorrect

    • A 30-year-old woman who is currently 8 weeks pregnant contacts the clinic to inquire about the results of her urine culture that was taken during her first antenatal visit. She reports no symptoms and has no known allergies to medications.

      The urine culture report indicates:

      Significant growth of Escherichia coli

      Trimethoprim Sensitive
      Nitrofurantoin Sensitive
      Cefalexin Sensitive

      What is the best course of treatment for this patient?

      Your Answer: Cefalexin (7 day course)

      Correct Answer: Nitrofurantoin (7 day course)

      Explanation:

      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.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 41 - A 55-year-old man has recently read about prostate cancer and asks whether he...

    Incorrect

    • A 55-year-old man has recently read about prostate cancer and asks whether he should undergo a digital rectal examination to assess his prostate.
      For which of the following would it be most appropriate to conduct a digital rectal examination (DRE) to assess prostate size and consistency?

      Your Answer: In an asymptomatic man whose grandfather died of prostate cancer in his 80s

      Correct Answer: In a patient with lower urinary tract symptoms (LUTS)

      Explanation:

      Prostate Cancer Screening and Testing: Important Considerations

      In patients with lower urinary tract symptoms (LUTS), it is important to consider the possibility of locally advanced prostate cancer causing obstructive LUTS. Therefore, a prostate-specific antigen (PSA) test and digital rectal exam (DRE) should be offered to men with obstructive symptoms.

      While family history is a significant risk factor for prostate cancer, a grandfather’s history of the disease may not be as significant as a first-degree relative’s (father or brother) history.

      If a man presents with symptoms of urinary tract infection, it is important to investigate and treat the infection before considering any PSA testing. Prostate cancer typically doesn’t cause symptoms of urinary tract infection.

      Currently, there is no formal screening program for prostate cancer. However, men may choose to request a PSA test after being informed of the potential benefits and risks. It is important to note that DRE alone should not be used for screening.

      Prior to testing for PSA, it is recommended to perform DRE at least a week prior as it can falsely elevate PSA levels.

      Key Considerations for Prostate Cancer Screening and Testing

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 42 - You are examining the most recent blood test results for a patient with...

    Correct

    • You are examining the most recent blood test results for a patient with type 2 diabetes mellitus who is in their 60s. The patient is currently taking simvastatin 20 mg, metformin 1g twice daily, and gliclazide 80 mg twice daily. The patient's latest renal function results are as follows:

      - Sodium (Na+): 141 mmol/l
      - Potassium (K+): 3.9 mmol/l
      - Urea: 5.2 mmol/l
      - Creatinine: 115 µmol/l

      What is the creatinine threshold at which NICE recommends considering a change in metformin dosage?

      Your Answer: > 130 µmol/l

      Explanation:

      If the creatinine level is above 130 micromol/l (or eGFR is below 45 ml/min), NICE suggests that the dosage of metformin should be reevaluated. Additionally, if the creatinine level is above 150 micromol/l (or eGFR is below 30 ml/min), NICE recommends that metformin should be discontinued.

      Metformin is a medication commonly used to treat type 2 diabetes mellitus, as well as polycystic ovarian syndrome and non-alcoholic fatty liver disease. Unlike other medications, such as sulphonylureas, metformin doesn’t cause hypoglycaemia or weight gain, making it a first-line treatment option, especially for overweight patients. Its mechanism of action involves activating the AMP-activated protein kinase, increasing insulin sensitivity, decreasing hepatic gluconeogenesis, and potentially reducing gastrointestinal absorption of carbohydrates. However, metformin can cause gastrointestinal upsets, reduced vitamin B12 absorption, and in rare cases, lactic acidosis, particularly in patients with severe liver disease or renal failure. It is contraindicated in patients with chronic kidney disease, recent myocardial infarction, sepsis, acute kidney injury, severe dehydration, and those undergoing iodine-containing x-ray contrast media procedures. When starting metformin, it should be titrated up slowly to reduce the incidence of gastrointestinal side-effects, and modified-release metformin can be considered for patients who experience unacceptable side-effects.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 43 - A 65-year-old man presents with haematuria. Investigations confirm the presence of a bladder...

    Correct

    • A 65-year-old man presents with haematuria. Investigations confirm the presence of a bladder carcinoma.
      In his occupational history, select the single substance exposure which would be a significant risk factor for his current diagnosis.

      Your Answer: Aromatic amines

      Explanation:

      Occupational and Environmental Carcinogens: A Brief Overview

      Exposure to certain chemicals and substances in the workplace and environment can increase the risk of developing cancer. Bladder carcinoma, for example, is linked to exposure to aromatic amines found in various industries such as dyes, paints, and textiles. Smoking is also a major contributor to bladder cancer. Asbestos, commonly found in construction materials, increases the risk of lung cancer and mesothelioma. Vinyl chloride, used in plastic production and tobacco smoke, is associated with liver cancer, brain cancer, lung cancer, lymphoma, and leukemia. Arsenic exposure predisposes individuals to skin cancer, while nickel exposure increases the risk of squamous-cell carcinomas in the lung and nasal cavity. It is important for individuals to be aware of potential carcinogens in their workplace and environment to take necessary precautions and reduce their risk of developing cancer.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 44 - Mr. Johnson is a 65-year-old man with multiple sclerosis who has a long...

    Incorrect

    • 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: Treat with a 7 day course of nitrofurantoin or trimethoprim

      Correct 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.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 45 - You have arranged a semen analysis for a 37-year-old man who has been...

    Incorrect

    • 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 as soon as possible

      Correct 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.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 46 - You are discussing with your supervisor the management of patients who present with...

    Incorrect

    • You are discussing with your supervisor the management of patients who present with urological symptoms in elderly women.
      Which of the following presentations of urinary symptoms in elderly women requires urgent referral?

      Your Answer: A 48-year-old asymptomatic patient with visible haematuria and no UTI

      Correct Answer: A 44-year-old patient with urinary incontinence symptoms and feeling of a 'lump down below'

      Explanation:

      Urgent Referral for Painless Visible Haematuria

      Painless macroscopic haematuria, or visible blood in the urine, is a concerning symptom that should be urgently referred for suspicion of bladder or renal cancer. However, it is important to note that if the patient also experiences pain or symptoms of a urinary tract infection, these should be assessed and managed separately.

      Prompt referral for painless visible haematuria is crucial in order to ensure timely diagnosis and treatment of potential cancer. Patients should be advised to seek medical attention immediately if they notice blood in their urine, even if they do not experience any pain or other symptoms. Healthcare providers should also be vigilant in identifying and referring these cases for further evaluation.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 47 - One of your elderly patients with chronic kidney disease stage 4 has undergone...

    Correct

    • One of your elderly patients with chronic kidney disease stage 4 has undergone his annual blood tests:

      Hb 9.4 g/dl
      Platelets 166 * 109/l
      WBC 6.7 * 109/l

      He is currently receiving treatment from the renal team and has been prescribed erythropoietin. What is the target haemoglobin level for this patient?

      Your Answer: 10-12 g/dl

      Explanation:

      The target for haemoglobin levels in CKD patients with anaemia should be between 10-12 g/dl.

      Anaemia in Chronic Kidney Disease

      Patients with chronic kidney disease (CKD) may develop anaemia due to various factors, with reduced erythropoietin levels being the most significant. This type of anaemia is usually normochromic normocytic and becomes apparent when the GFR is less than 35 ml/min. Other causes of anaemia should be considered if the GFR is greater than 60 ml/min. Anaemia in CKD can lead to the development of left ventricular hypertrophy, which is associated with a three-fold increase in mortality in renal patients.

      There are several causes of anaemia in renal failure, including reduced erythropoietin levels, reduced erythropoiesis due to toxic effects of uraemia on bone marrow, reduced absorption of iron, anorexia/nausea due to uraemia, reduced red cell survival (especially in haemodialysis), blood loss due to capillary fragility and poor platelet function, and stress ulceration leading to chronic blood loss.

      To manage anaemia in CKD, the 2011 NICE guidelines suggest a target haemoglobin of 10-12 g/dl. Determination and optimisation of iron status should be carried out before the administration of erythropoiesis-stimulating agents (ESA). Oral iron should be offered for patients who are not on ESAs or haemodialysis. If target Hb levels are not reached within three months, patients should be switched to IV iron. Patients on ESAs or haemodialysis generally require IV iron. ESAs such as erythropoietin and darbepoetin should be used in those who are likely to benefit in terms of quality of life and physical function.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 48 - A 49-year-old man presents with left loin pain which has been present for...

    Incorrect

    • A 49-year-old man presents with left loin pain which has been present for the last four to six weeks. He has no significant past medical history and takes no regular medications.

      The pain doesn't radiate from the left loin and it is not mechanical in nature. It is constant and has started to disturb his sleep at night. He reports that he is opening his bowels normally and denies any lower urinary tract symptoms. Systems review reveals he has lost just over half a stone in weight over the last two months. He tells you he also feels more tired over the last few months.

      On examination there is no tenderness on palpation of the lower back at the site of pain. The overlying skin is normal and no masses are felt. Truncal movements and walking do not exacerbate the pain. Abdominal examination is normal. There are no groin abnormalities palpated. A left sided varicocoele is noted. His blood pressure is elevated at 178/98 mmHg.

      What is the next best course of action in primary care to aid in establishing a diagnosis for this 49-year-old man?

      Your Answer: Urine dipstick testing

      Correct Answer: Faecal occult blood testing

      Explanation:

      Signs and Symptoms of Renal Carcinoma

      This patient is displaying signs and symptoms that suggest a possible renal carcinoma. The presence of non-mechanical back pain, weight loss, tiredness, hypertension, and left sided varicocoele should alert the clinician to consider a renal cause. It is important to rule out musculoskeletal causes for the back pain and to check for the presence of blood in the urine through a dipstick test.

      Renal tumours are often picked up by ultrasound, with haematuria and PUO being more common presentations than pain. It is worth noting that renal and retroperitoneal tumours may cause obstruction of the left testicular vein, leading to a left-sided varicocoele. Therefore, if a varicocoele is found on testicular imaging, the kidneys should also be scanned for any masses. Overall, it is crucial to consider a renal aetiology when presented with these symptoms.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 49 - A 57-year-old man is found to have an average blood pressure of 163/101...

    Incorrect

    • A 57-year-old man is found to have an average blood pressure of 163/101 mmHg on home monitoring. Baseline bloods show a creatinine (Cr) of 95 µmol/l (normal range: 50–120 µmol/l) and estimated glomerular filtration rate (eGFR) of 80 ml/min (normal range: > 90 ml/min). His urine albumin : creatinine ratio (ACR) is 2.8 (normal range: < 3 mg/mmol).
      He is commenced on ramipril 2.5 mg once daily. He tolerates this well and returns to his General Practice Surgery for blood tests two weeks later, which show a Cr level of 125 µmol/l and an eGFR level of 62 mg/mmol.
      What is the most likely cause for the change in this man’s renal function?

      Your Answer: Concomitant use of non-steroidal anti-inflammatory drugs (NSAIDs)

      Correct Answer: Renal artery stenosis (RAS)

      Explanation:

      Differential diagnosis of acute kidney injury after starting ACE inhibitors

      Angiotensin-converting enzyme (ACE) inhibitors are commonly used to treat hypertension and heart failure, but they can also cause a decline in renal function, especially in patients with renal artery stenosis (RAS). Therefore, it is important to monitor renal function before and after initiating or adjusting ACE inhibitors, especially in patients with risk factors for RAS. In this case, a patient who started ramipril developed a reduction in estimated glomerular filtration rate (eGFR), which was consistent with underlying RAS.

      Other potential causes of acute kidney injury (AKI) in this patient include dehydration, progression of chronic kidney disease (CKD), hypertensive nephropathy, and concomitant use of non-steroidal anti-inflammatory drugs (NSAIDs). However, the absence of relevant history or laboratory findings makes these diagnoses less likely. Dehydration can cause AKI, but there is no evidence of volume depletion or electrolyte imbalance. CKD is unlikely given the normal urine albumin-to-creatinine ratio (ACR) and lack of prior renal dysfunction. Hypertensive nephropathy is a chronic condition that typically manifests as proteinuria and gradual decline in renal function, rather than an acute response to antihypertensive treatment. NSAIDs can exacerbate renal impairment in patients with preexisting renal insufficiency, but there is no indication that the patient was taking any NSAIDs.

      Therefore, the most likely explanation for the AKI in this patient is the use of ACE inhibitors, which can reduce intraglomerular pressure and renal perfusion in patients with RAS. This highlights the importance of considering the differential diagnosis of AKI in patients who start or change antihypertensive medications, especially ACE inhibitors, and monitoring renal function accordingly.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 50 - A 62-year-old man presents to his General Practitioner with bothersome urinary symptoms of...

    Incorrect

    • 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:

      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.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 51 - You receive a fax through from urology. One of your patients in their...

    Incorrect

    • 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:

      Correct 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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      • Kidney And Urology
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  • Question 52 - A 70-year-old man with a history of type 2 diabetes mellitus and peripheral...

    Incorrect

    • A 70-year-old man with a history of type 2 diabetes mellitus and peripheral artery disease is prescribed ramipril for newly diagnosed stage 2 hypertension. After 10 days, his repeat U&Es show a decline in renal function. What is the probable cause of this deterioration?

      Before starting ramipril, his U&Es were within normal limits, with a sodium level of 141 mmol/L (135 - 145), potassium level of 4.6 mmol/L (3.5 - 5.0), bicarbonate level of 24 mmol/L (22 - 29), urea level of 3.2 mmol/L (2.0 - 7.0), and creatinine level of 78 µmol/L (55 - 120). However, ten days later, his U&Es showed an increase in urea level to 8.8 mmol/L (2.0 - 7.0) and creatinine level to 128 µmol/L (55 - 120), while his sodium and potassium levels remained stable and his bicarbonate level increased to 26 mmol/L (22 - 29).

      Your Answer:

      Correct Answer: Bilateral renal artery stenosis

      Explanation:

      If a patient with undiagnosed bilateral renal artery stenosis starts taking an ACE inhibitor, they may experience significant renal impairment. Therefore, it is important to consider the possibility of bilateral renal artery stenosis in patients with risk factors for atherosclerotic vascular disease, especially if they develop hypertension later in life and experience a sudden drop in renal function after starting an ACE inhibitor. This acute decline in renal function is not consistent with chronic kidney conditions like diabetic or hypertensive nephropathy. Glomerulonephritis or pre-renal acute kidney injury from dehydration are unlikely based on the information provided.

      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. ACE inhibitors are also used to treat diabetic nephropathy and prevent ischaemic heart disease. These drugs work by inhibiting the conversion of angiotensin I to angiotensin II and are metabolized in the liver.

      While ACE inhibitors are generally well-tolerated, they can cause side effects such as cough, angioedema, hyperkalaemia, and first-dose hypotension. Patients with certain conditions, such as renovascular disease, aortic stenosis, or hereditary or idiopathic angioedema, should use ACE inhibitors with caution or avoid them altogether. Pregnant and breastfeeding women should also avoid these drugs.

      Patients taking high-dose diuretics may be at increased risk of hypotension when using ACE inhibitors. Therefore, it is important to monitor urea and electrolyte levels before and after starting treatment, as well as any changes in creatinine and potassium levels. Acceptable changes include a 30% increase in serum creatinine 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 when using ACE inhibitors.

      The current NICE guidelines recommend using a flow chart to manage hypertension, with ACE inhibitors as the first-line treatment for patients under 55 years old. However, individual patient factors and comorbidities should be taken into account when deciding on the best treatment plan.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 53 - You encounter a 45-year-old Afro-Caribbean man who wishes to discuss his struggles with...

    Incorrect

    • You encounter a 45-year-old Afro-Caribbean man who wishes to discuss his struggles with erectile dysfunction. He has been experiencing difficulty achieving and maintaining erections for the past 8 months.

      The patient's medical history includes hypertension and sickle cell disease, for which he takes ramipril and amlodipine. He maintains a healthy body mass index and regularly exercises for an hour five days a week, primarily using the treadmill and weights. He doesn't smoke but consumes approximately 4 units of alcohol daily.

      What is the risk factor for erectile dysfunction in this patient?

      Your Answer:

      Correct Answer: High alcohol intake

      Explanation:

      Erectile dysfunction (ED) is not a disease but a symptom that can be caused by various factors, including organic and psychogenic causes, as well as certain drugs. Some drugs that can cause ED include antihypertensives, diuretics, antidepressants, and recreational drugs like marijuana. High alcohol intake is also a well-known cause of ED, and this risk is increased when a person drinks more than the recommended safe amount.

      Among the organic causes of ED, vasculogenic causes are the most common, including cardiovascular disease, hypertension, hyperlipidemia, diabetes mellitus, and smoking. By modifying risk factors and receiving treatment, most patients can experience significant improvement. This includes controlling blood pressure and lipid levels, losing weight, quitting smoking, increasing exercise, and reducing alcohol intake. However, excessive cycling can worsen ED.

      Treatment for ED often involves the use of phosphodiesterase inhibitors (PDE5), unless there are contraindications. For instance, sickle cell disease increases the risk of priapism (persistent erection), so caution is necessary when prescribing PDE5 inhibitors to patients with this condition. However, sickle cell disease doesn’t increase the risk of ED per se.

      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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      • Kidney And Urology
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  • Question 54 - A 58-year-old woman presents with painless haematuria. She is a heavy smoker and...

    Incorrect

    • A 58-year-old woman presents with painless haematuria. She is a heavy smoker and has a history of chronic obstructive pulmonary disease. She previously lived in Australia and has used substantial amounts of non-steroidal anti-inflammatory drugs for arthritis and also phenacetin some years ago. Renal function testing is normal. She has a raised plasma viscosity and is anaemic with a haemoglobin of 100 g/l (115-155).
      Select the most likely diagnosis to fit with this clinical picture.

      Your Answer:

      Correct Answer: Transitional-cell carcinoma of the bladder

      Explanation:

      Bladder Cancer: Risk Factors, Presentation, and Survival Rates

      Bladder cancer is a relatively uncommon malignancy, accounting for around 3% of cancer deaths. It is more prevalent in males, with a male to female ratio of 4:1, and is rare in individuals under 40 years of age. The most common type of bladder cancer is transitional-cell carcinoma.

      Several risk factors have been identified, including smoking, exposure to certain chemicals found in industrial settings, and the use of certain medications such as phenacetin and cyclophosphamide. Chronic inflammation caused by conditions such as schistosomiasis, indwelling catheters, or stones is associated with squamous-cell carcinoma of the bladder.

      The most common presentation of bladder cancer is painless hematuria (blood in the urine), although pain may occur due to clot retention. Women are more likely to have muscle-invasive disease at presentation.

      The 5-year survival rate for bladder cancer varies depending on the stage of the disease at diagnosis. Patients with small, early superficial tumors have a survival rate of 80-90%, while those with metastases at presentation have a survival rate of only 5%.

      In conclusion, bladder cancer is a serious condition that can be caused by a variety of factors. Early detection and treatment are crucial for improving survival rates.

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      • Kidney And Urology
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  • Question 55 - A 50-year-old man has long-standing treated hypertension. He has had his estimated glomerular...

    Incorrect

    • A 50-year-old man has long-standing treated hypertension. He has had his estimated glomerular filtration rate (eGFR) measured on an annual basis. Last year, his eGFR was estimated at 56 ml/minute/1.73 m². This year, he has an unexplained fall in eGFR to 41 ml/minute/1.73 m². This is confirmed by a second blood sample. He feels otherwise well.
      What is the most appropriate action?

      Your Answer:

      Correct Answer: Routine outpatient referral to the renal team

      Explanation:

      Referral and Management of Chronic Kidney Disease Patients

      Chronic kidney disease (CKD) is a common condition that requires appropriate management to prevent progression and complications. The National Institute for Health and Care Excellence (NICE) has provided guidelines on when to refer CKD patients for specialist assessment. Patients with a glomerular filtration rate (GFR) less than 30 ml/min/1.73 m2, albumin creatinine ratio (ACR) of 70 mg/mmol or more, sustained decrease in GFR, poorly controlled hypertension, rare or genetic causes of CKD, or suspected renal artery stenosis should be referred for review by a renal team.

      In addition to referral, patients with CKD may require further investigations such as renal ultrasound. An ultrasound is indicated in patients with rapid deterioration of eGFR, visible or persistent microscopic haematuria, symptoms of urinary tract obstruction, family history of polycystic kidney disease, or GFR drops to under 30. However, the results of an ultrasound should not determine referral.

      Patients with CKD require regular monitoring, but the frequency of monitoring depends on the stage and progression of the disease. Patients with a rapid drop in eGFR, like the patient in this case, require specialist input and should not continue with annual monitoring. However, urgent medical review is only necessary in cases of severe complications such as hyperkalaemia, severe uraemia, acidosis, or fluid overload.

      In summary, appropriate referral and management of CKD patients can prevent complications and improve outcomes. NICE guidelines provide clear indications for referral and investigations, and regular monitoring is necessary to track disease progression.

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  • Question 56 - A 32-year-old man needs to take naproxen to relieve the symptoms of ankylosing...

    Incorrect

    • A 32-year-old man needs to take naproxen to relieve the symptoms of ankylosing spondylitis.
      Select from the list the single most important item that should be regularly monitored.

      Your Answer:

      Correct Answer: Renal function

      Explanation:

      Renal Adverse Drug Reactions Associated with NSAIDs

      Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used for pain relief, but they come with a relatively high incidence of renal adverse drug reactions. These reactions are caused by changes in renal haemodynamics, which are usually mediated by prostaglandins that are affected by NSAIDs. Patients with renal impairment should avoid these drugs if possible, or use them with caution. It is important to use the lowest effective dose for the shortest possible duration and monitor renal function. NSAIDs may cause sodium and water retention, leading to deterioration of renal function and possibly renal failure. Therefore, it is crucial to be aware of the potential renal adverse drug reactions associated with NSAIDs.

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  • Question 57 - A 76-year-old man has been experiencing widespread aches and pains in his chest,...

    Incorrect

    • A 76-year-old man has been experiencing widespread aches and pains in his chest, back, and hips for several months. He also reports difficulty with urinary flow and frequent nighttime urination. What is the most suitable course of action?

      Your Answer:

      Correct Answer: Check prostate-specific antigen (PSA) levels

      Explanation:

      Prostate Cancer and Prostatism: Symptoms and Diagnosis

      Patients with prostatism who experience bony pain should be evaluated for prostate cancer, as it often metastasizes to bone. A digital rectal examination should be performed after taking blood for PSA, as the prostate will typically feel hard and irregular in cases of prostate cancer. While chronic urinary retention and urinary infection may be present, investigations should focus on identifying the underlying cause rather than providing symptomatic treatment with an α-blocker. Without a confirmed diagnosis of benign prostatic hyperplasia, finasteride should not be prescribed.

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      • Kidney And Urology
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  • Question 58 - A 53-year-old man presents to the GUM clinic with a swollen, tender, and...

    Incorrect

    • A 53-year-old man presents to the GUM clinic with a swollen, tender, and red glans penis that he has been experiencing for the past five days. He is unable to retract his foreskin fully and is experiencing pain while urinating. He has no history of sexual activity and has been treated for balanitis three times in the past year with saline baths and topical clotrimazole, despite testing negative for sexually transmitted and bacterial infections. He has a medical history of diabetes mellitus.

      After treating the acute episode with saline baths and topical clotrimazole, what is the most appropriate next step in managing this patient?

      Your Answer:

      Correct Answer: Refer for circumcision

      Explanation:

      Recurrent balanitis can be effectively treated with circumcision.

      Balanitis, which is characterized by inflammation of the glans penis, can be caused by various factors such as sexually transmitted infections, dermatitis, bacterial infections, or fungal infections like Candida. In this case, the patient’s diabetes has made them susceptible to opportunistic fungal infections.

      For acute infections, treatment involves addressing the underlying cause and using saline baths. Topical treatments like hydrocortisone, clotrimazole, miconazole, or nystatin cream may also be recommended depending on the cause of the infection.

      However, if the balanitis keeps recurrent, circumcision is the most appropriate treatment option. This procedure can effectively prevent the condition from happening again.

      Understanding Circumcision

      Circumcision is a practice that has been carried out in various cultures for centuries. Today, it is mainly practiced by people of the Jewish and Islamic faith for religious or cultural reasons. However, it is important to note that circumcision for these reasons is not available on the NHS.

      The medical benefits of circumcision are still a topic of debate. However, some studies have shown that it can reduce the risk of penile cancer, urinary tract infections, and sexually transmitted infections, including HIV.

      There are also medical indications for circumcision, such as phimosis, recurrent balanitis, balanitis xerotica obliterans, and paraphimosis. It is crucial to rule out hypospadias before performing circumcision as the foreskin may be needed for surgical repair.

      Circumcision can be performed under local or general anesthesia. It is a personal decision that should be made after careful consideration of the potential benefits and risks.

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  • Question 59 - A 62-year-old woman undergoes a routine health assessment. She feels well, has never...

    Incorrect

    • A 62-year-old woman undergoes a routine health assessment. She feels well, has never smoked, and has no complaints. The examination is unremarkable. Investigations reveal microscopic haematuria in the urine and the following results. She has no pain, dysuria and was not exercising prior to collection.

      Hb 140 g/L
      Platelets 280 * 109/L (150 - 400)
      WBC 12 * 109/L (4.0 - 11.0)

      What is the most appropriate course of action in this scenario?

      Your Answer:

      Correct Answer: Urgent (2-week) referral to a urologist

      Explanation:

      If a patient aged 60 or over presents with unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test, it is important to exclude bladder cancer. Referral using the suspected cancer pathway should be made within 2 weeks. The urologist may request investigations such as a urine red cell morphology, CT intravenous pyelogram, and urine cytology. However, CT kidneys, ureter and bladder is not appropriate at this stage as it assesses radio-opaque stones in the renal tract. Routine referral to a urologist is also not ideal if bladder cancer is suspected. In resource-poor settings, the GP should commence relevant investigations for bladder cancer while waiting for the urology appointment. Reassuring and re-checking in two weeks or six weeks may be appropriate for lower risk cases.

      Bladder cancer is a common urological cancer that primarily affects males aged 50-80 years old. Smoking and exposure to hydrocarbons increase the risk of developing the disease. Chronic bladder inflammation from Schistosomiasis infection is also a common cause of squamous cell carcinomas in countries where the disease is endemic. Benign tumors of the bladder, such as inverted urothelial papilloma and nephrogenic adenoma, are rare. The most common bladder malignancies are urothelial (transitional cell) carcinoma, squamous cell carcinoma, and adenocarcinoma. Urothelial carcinomas may be solitary or multifocal, with papillary growth patterns having a better prognosis. The remaining tumors may be of higher grade and prone to local invasion, resulting in a worse prognosis.

      The TNM staging system is used to describe the extent of bladder cancer. Most patients present with painless, macroscopic hematuria, and a cystoscopy and biopsies or TURBT are used to provide a histological diagnosis and information on depth of invasion. Pelvic MRI and CT scanning are used to determine locoregional spread, and PET CT may be used to investigate nodes of uncertain significance. Treatment options include TURBT, intravesical chemotherapy, surgery (radical cystectomy and ileal conduit), and radical radiotherapy. The prognosis varies depending on the stage of the cancer, with T1 having a 90% survival rate and any T, N1-N2 having a 30% survival rate.

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  • Question 60 - A 70-year-old patient with rheumatoid arthritis presents with symptoms consistent with membranous glomerulonephritis.
    Which...

    Incorrect

    • A 70-year-old patient with rheumatoid arthritis presents with symptoms consistent with membranous glomerulonephritis.
      Which of the following drugs is most likely be responsible?

      Your Answer:

      Correct Answer: Gold

      Explanation:

      Renal Complications in Rheumatoid Arthritis Treatment

      Rheumatoid arthritis is a chronic autoimmune disease that affects the joints and can lead to disability. The use of gold, penicillamine, and non-steroidal anti-inflammatory agents as disease-modifying drugs in the treatment of rheumatoid arthritis can result in renal complications. Membranous glomerulonephritis is a common complication that occurs due to the widespread thickening of the glomerular basement membrane. Immunofluorescence reveals granular deposits of immunoglobulin and complement. Methotrexate, another drug used in the treatment of rheumatoid arthritis, can also be toxic to the kidney in large doses. However, such doses are unlikely in patients with rheumatoid arthritis. It is important for healthcare providers to monitor renal function in patients receiving these medications to prevent renal complications.

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  • Question 61 - A 30-year-old patient who has been under your care for four years contacts...

    Incorrect

    • 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:

      Correct 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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  • Question 62 - Evelyn, an 80-year-old woman visits the clinic for a medication review. She has...

    Incorrect

    • Evelyn, an 80-year-old woman visits the clinic for a medication review. She has a medical history of well-controlled osteoarthritis, chronic obstructive pulmonary disease, and chronic kidney disease (CKD). Currently, she takes Symbicort (budesonide with formoterol) 200/6, salbutamol, and uses senna and naproxen tablets as required.

      Her recent urine sample indicates an albumin:creatinine ratio (ACR) of 87 mg/mmol, which is higher than the previous sample taken 6 months ago, showing an ACR of 79 mg/mmol. Additionally, her serum urea and creatinine results have mildly deteriorated over the last 6 months.

      During her clinic visit, her blood pressure measures 129/76 mmHg.

      What medication changes would you suggest for Evelyn?

      Your Answer:

      Correct Answer: Start ramipril and atorvastatin, consider alternatives to naproxen

      Explanation:

      Patients who have chronic kidney disease and a urinary ACR of 70 mg/mmol or more should be prescribed an ACE inhibitor, according to NICE guidelines. Additionally, all patients with CKD should be prescribed a statin for the prevention of cardiovascular disease. In the case of a patient experiencing a decline in renal function, it may be advisable to discontinue the use of naproxen, although this decision should be made in consideration of the patient’s symptoms and functional impairment. The recommended course of action would be to start the patient on ramipril and atorvastatin while exploring alternative treatments for osteoarthritis. The second option is only partially correct, as ramipril is advised regardless of blood pressure in CKD patients with this level of proteinuria. The third option doesn’t include ramipril or atorvastatin, while the fourth and fifth options do not include atorvastatin. Ultimately, the decision to discontinue naproxen use will depend on the healthcare professional’s clinical judgement, the patient’s preferences, and the frequency of use.

      Proteinuria in Chronic Kidney Disease: Diagnosis and Management

      Proteinuria is a significant indicator of chronic kidney disease, particularly in cases of diabetic nephropathy. The National Institute for Health and Care Excellence (NICE) recommends using the albumin:creatinine ratio (ACR) over the protein:creatinine ratio (PCR) for identifying patients with proteinuria due to its higher sensitivity. PCR can be used for quantification and monitoring of proteinuria, but ACR is preferred for diabetics. Urine reagent strips are not recommended unless they express the result as an ACR.

      To collect an ACR sample, a first-pass morning urine specimen is preferred as it avoids the need to collect urine over a 24-hour period. If the initial ACR is between 3 mg/mmol and 70 mg/mmol, a subsequent early morning sample should confirm it. However, if the initial ACR is 70 mg/mmol or more, a repeat sample is unnecessary.

      According to NICE guidelines, a confirmed ACR of 3 mg/mmol or more is considered clinically important proteinuria. Referral to a nephrologist is recommended for patients with a urinary ACR of 70 mg/mmol or more, unless it is known to be caused by diabetes and already appropriately treated. Referral is also necessary for patients with an ACR of 30 mg/mmol or more, along with persistent haematuria after exclusion of a urinary tract infection. For patients with an ACR between 3-29 mg/mmol and persistent haematuria, referral to a nephrologist is considered if they have other risk factors such as declining eGFR or cardiovascular disease.

      The frequency of monitoring eGFR varies depending on the eGFR and ACR categories. ACE inhibitors or angiotensin II receptor blockers are key in managing proteinuria and should be used first-line in patients with coexistent hypertension and CKD if the ACR is > 30 mg/mmol. If the ACR is > 70 mg/mmol, they are indicated regardless of the patient’s blood pressure.

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  • Question 63 - 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 10.5 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 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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  • Question 64 - A 56-year-old woman presents to your clinic with a complaint of frequent urine...

    Incorrect

    • A 56-year-old woman presents to your clinic with a complaint of frequent urine leakage. What is the initial method to evaluate urinary incontinence or overactive bladder in women?

      Your Answer:

      Correct Answer: Trial of therapy

      Explanation:

      Importance of a Bladder Diary in Assessing Urinary Incontinence

      A bladder diary is a crucial tool in the initial assessment of urinary incontinence or overactive bladder syndrome in women. It helps to identify patterns and triggers of urinary symptoms, which can aid in the diagnosis and treatment of the condition. Women should be encouraged to complete a minimum of three days of the diary to cover variations of their usual activities, including work and leisure time.

      By keeping track of their urinary habits, women can provide their healthcare provider with valuable information about their symptoms, such as frequency, urgency, and leakage. This information can help the provider to determine the type and severity of the condition and develop an appropriate treatment plan. Therefore, it is essential for women to use a bladder diary when experiencing urinary incontinence or overactive bladder syndrome.

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  • Question 65 - A 55-year-old woman presents with haematuria and severe right flank pain. She is...

    Incorrect

    • A 55-year-old woman presents with haematuria and severe right flank pain. She is agitated and unable to find a position that relieves the pain. On physical examination, there is tenderness in the right lumbar region, but her abdomen is soft. She has no fever.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Renal calculi

      Explanation:

      Symptoms and Presentations of Various Kidney Conditions

      Kidney conditions can present with a variety of symptoms and presentations. Renal colic, caused by the passage of stones into the ureter, is characterized by severe flank pain that radiates to the groin, along with haematuria, nausea, and vomiting. Acute pyelonephritis presents with fever, costovertebral angle pain, and nausea/vomiting, while acute glomerulonephritis doesn’t cause severe loin pain. Autosomal dominant polycystic kidney disease can cause chronic loin pain, but it is not as severe as renal colic unless there is a stone present. Renal cell carcinoma may present with haematuria, loin pain, and a flank mass, but the pain is not as severe as in renal colic and pyrexia is only present in a minority of cases.

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  • Question 66 - You are seeing a 60-year-old gentleman who has presented with a three day...

    Incorrect

    • You are seeing a 60-year-old gentleman who has presented with a three day history of dysuria and frequency of urination. There is no reported visible haematuria. He has no history of urinary tract infections, however, he does report longstanding problems with poor urinary stream, hesitancy of urination, and nocturia.

      Clinical examination of his abdomen and loins is unremarkable and he has no fever or systemic upset.

      Urine dipstick testing shows:
      nitrites positive
      leucocytes ++
      protein ++
      blood ++.

      You diagnose a urinary tract infection, send a urine sample to the laboratory for analysis, and treat him with a course of antibiotics.

      You go on to chat about his more longstanding lower urinary tract symptoms. Following this discussion, he is keen to have a rectal examination and prostate-specific antigen (PSA) blood test. Digital rectal examination reveals a smoothly enlarged benign feeling prostate.

      Two days later, the laboratory urine results return confirming a urinary tract infection.

      When is the most appropriate time to perform a PSA blood test in this case?

      Your Answer:

      Correct Answer: The test can be performed any time from now

      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, or 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 the person has recently ejaculated or exercised vigorously in the past 48 hours, the test should also be postponed. While some sources suggest delaying PSA testing for at least a week after a digital rectal examination, studies have shown that rectal examination has minimal impact on PSA levels.

      In summary, several factors can affect the results of the PSA blood test, and it is crucial to consider these factors before interpreting the test results accurately.

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  • Question 67 - 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.

      What is an example of a medication that falls under the category of muscarinic antagonist?

      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.

      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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  • Question 68 - A 60-year-old man has had several cystoscopies for the transurethral resection of superficial...

    Incorrect

    • A 60-year-old man has had several cystoscopies for the transurethral resection of superficial bladder tumours and for regular surveillance. He complains of urinary frequency, a poor urinary stream, spraying of urine and dribbling at the end of micturition. These symptoms he has noticed for about a year. On digital rectal examination, his prostate is smooth, soft and normal in size. His prostate-specific antigen level is 2 ng/ml.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Urethral stricture

      Explanation:

      Urethral Stricture: Causes, Complications, and Treatments

      Urethral strictures are commonly caused by injury, urethral instrumentation, and infections such as gonorrhoea or chlamydia. In this case, the repeated cystoscopies are a likely cause. This condition can lead to complications such as urinary retention and urinary infection.

      To treat urethral strictures, periodic dilation, internal urethrotomy, and external urethroplasty are common options. It is important to note that a normal feeling prostate, a normal prostate-specific antigen level, and regular bladder tumour surveillance make other diagnoses less likely in this case.

      In summary, understanding the causes, complications, and treatments of urethral strictures is crucial for proper management of this condition.

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  • Question 69 - Care should always be taken when combining diuretics. However, which one of the...

    Incorrect

    • Care should always be taken when combining diuretics. However, which one of the following combinations is always contraindicated?

      Your Answer:

      Correct Answer: Amiloride + spironolactone

      Explanation:

      Potassium-sparing diuretics are classified into two types: epithelial sodium channel blockers (such as amiloride and triamterene) and aldosterone antagonists (such as spironolactone and eplerenone). However, caution should be exercised when using these drugs in patients taking ACE inhibitors as they can cause hyperkalaemia. Amiloride is a weak diuretic that blocks the epithelial sodium channel in the distal convoluted tubule. It is usually given with thiazides or loop diuretics as an alternative to potassium supplementation since these drugs often cause hypokalaemia. On the other hand, aldosterone antagonists like spironolactone act in the cortical collecting duct and are used to treat conditions such as ascites, heart failure, nephrotic syndrome, and Conn’s syndrome. In patients with cirrhosis, relatively large doses of spironolactone (100 or 200 mg) are often used to manage secondary hyperaldosteronism.

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  • Question 70 - A 22-year-old woman presents for follow-up. She had an episode of acute cystitis...

    Incorrect

    • A 22-year-old woman presents for follow-up. She had an episode of acute cystitis 4 weeks ago, which was successfully treated without any complications. Her urine culture did not show any resistant or atypical organisms. However, she has a history of recurrent lower UTIs and is feeling frustrated as she has had 6 episodes in the past year, which has put a strain on her new relationship. She has tried cranberry juice and probiotics, but they did not provide any relief.

      You ordered an abdominal ultrasound, which came back normal, and her post-void volume was 25 ml. After reviewing her behavioral and self-hygiene measures, you have identified sexual intercourse as the only trigger.

      What would be the most appropriate next step?

      Your Answer:

      Correct Answer: Prescribe oral antibiotic prophylaxis for single-dose use with sexual intercourse

      Explanation:

      For women who experience regular urinary tract infections (UTIs) following sexual intercourse, the recommended course of action is to prescribe a single-dose oral antibiotic prophylaxis to be taken with sexual intercourse. This is in line with NICE guidance, which also advises first-line measures such as avoiding douching and occlusive underwear, wiping from front to back after defecation, and maintaining adequate hydration. Daily antibiotic prophylaxis is not recommended for premenopausal, non-pregnant women with an identifiable trigger, but may be considered for those who continue to have recurrences with single-dose antibiotic prophylaxis regimens. Vaginal oestrogen cream is recommended for postmenopausal women, while referral to secondary care is only necessary for certain groups, such as those with suspected cancer or persistent haematuria. A self-taken vulvovaginal swab for STIs is not necessary unless there are symptoms of vulvovaginitis, cervicitis, or pelvic inflammatory disease.

      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 bacteriuria, 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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  • Question 71 - A digital rectal examination and PSA test should be offered to which of...

    Incorrect

    • A digital rectal examination and PSA test should be offered to which of the following patients?

      Your Answer:

      Correct Answer: A 62-year-old man with unexplained lower back pain

      Explanation:

      According to NICE guidelines, men experiencing unexplained symptoms such as erectile dysfunction, haematuria, lower back pain, bone pain, and weight loss (especially in the elderly) should be offered a PR and PSA test. However, before conducting a PSA test, a urine dipstick/MSU should be done to rule out any infection. If a UTI is treated, PSA testing should be avoided for at least a month.

      If the age-specific PSA is high or increasing, even in asymptomatic patients with a normal PR examination, an urgent referral should be made. In cases where the PSA is at the upper limit of normal in asymptomatic patients, a repeat PSA should be conducted after 1-3 months. If the PSA is increasing, an urgent referral should be made. These guidelines are outlined in the NICE referral guidelines for suspected cancer.

      Understanding Prostate Cancer: Features and Risk Factors

      Prostate cancer is a prevalent type of cancer among adult males in the UK, and it is the second leading cause of cancer-related deaths in men, next to lung cancer. Several risk factors increase the likelihood of developing prostate cancer, including increasing age, obesity, Afro-Caribbean ethnicity, and a family history of the disease. In fact, around 5-10% of cases have a strong family history.

      Localised prostate cancer is often asymptomatic, which means that it doesn’t show any symptoms. This is because the cancer cells tend to develop in the periphery of the prostate, which doesn’t cause obstructive symptoms early on. However, some possible features of prostate cancer include bladder outlet obstruction, hesitancy, urinary retention, haematuria, haematospermia, pain in the back, perineal or testicular area, and an asymmetrical, hard, nodular enlargement with loss of median sulcus during a digital rectal examination.

      Understanding the features and risk factors of prostate cancer is crucial in detecting and treating the disease early on. In some cases, prostate cancer may metastasize or spread to other parts of the body, such as the bones. A bone scan using technetium-99m labelled diphosphonates can detect multiple osteoblastic metastasis, which is a common finding in patients with metastatic prostate cancer.

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  • Question 72 - You encounter a 60-year-old man with diabetes and hypertension who reports experiencing erectile...

    Incorrect

    • You encounter a 60-year-old man with diabetes and hypertension who reports experiencing erectile dysfunction for the past 6 months. After prescribing sildenafil, which provided some relief, you increased the dosage but the patient is now experiencing adverse effects. He is curious about other treatment options available to him through the NHS. What medications can be prescribed for his condition?

      Your Answer:

      Correct Answer: Generic sildenafil, other PDE5 inhibitors and alprostadil

      Explanation:

      Men who have diabetes may be prescribed other PDE5 inhibitors and alprostadil on the NHS. Generic sildenafil is available without any restrictions on the NHS. However, Viagra®, tadalafil (Cialis®), vardenafil (Levitra®), avanafil (Spedra®), and alprostadil cannot be prescribed on an NHS prescription, except for men who have certain medical conditions or have undergone specific medical procedures. Additionally, specialist centers may prescribe PDE-5 inhibitors on the NHS if the man is experiencing severe distress due to impotence.

      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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  • Question 73 - A 68-year-old woman comes to her doctor complaining of dysuria and increased urinary...

    Incorrect

    • A 68-year-old woman comes to her doctor complaining of dysuria and increased urinary frequency. She is in good health otherwise and doesn't show any signs of sepsis. During a urine dip test at the doctor's office, blood, leukocytes, protein, and nitrites are detected. The patient has a medical history of asthma, which is treated with salbutamol and beclomethasone inhalers, hypertension, which is treated with amlodipine 10 mg daily and ramipril 5mg daily, and stage 3 chronic kidney disease.

      Which antibiotic should be avoided when treating this patient's urinary tract infection?

      Your Answer:

      Correct Answer: Nitrofurantoin

      Explanation:

      Patients with CKD stage 3 or higher should avoid taking nitrofurantoin due to the risk of treatment failure and side effects caused by drug accumulation. Nitrofurantoin is an antibiotic that requires adequate renal filtration to be effective in treating urinary tract infections. However, in patients with an eGFR of less than 40-60 ml/min, the drug is ineffective and can accumulate, leading to potential toxicity. Nitrofurantoin can also cause side effects such as peripheral neuropathy, hepatotoxicity, and pulmonary reactions. Amoxicillin and co-amoxiclav are safer options for treating urinary tract infections in patients with renal impairment, while ciprofloxacin may require dose reduction from an eGFR of 30-60 ml/min to avoid crystalluria. Patients taking nitrofurantoin should be aware that it can discolour urine and is safe to use during pregnancy except at full term.

      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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  • Question 74 - A 50-year-old man presents to the General Practitioner with a painful, persistent erection...

    Incorrect

    • 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:

      Correct 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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  • Question 75 - A 72-year-old diabetic woman is in her seventh year of haemodialysis. She visits...

    Incorrect

    • A 72-year-old diabetic woman is in her seventh year of haemodialysis. She visits her General Practitioner with symptoms of pain, numbness and tingling in both hands during the early hours of the morning. She also complains of stiffness in her shoulders, hips and knees.
      What diagnosis best fits with this clinical picture?

      Your Answer:

      Correct Answer: Dialysis amyloidosis

      Explanation:

      Differential Diagnosis for a Patient with Carpal Tunnel Syndrome, Shoulder Pain, and Flexor Tenosynovitis

      Dialysis Amyloidosis: A Likely Diagnosis

      The patient in question has been undergoing dialysis therapy for six years, which puts them at risk for dialysis amyloidosis. This condition occurs due to the accumulation of beta-2-microglobulin (B2M) in the body, which is not effectively cleared during dialysis. Symptoms of B2M amyloidosis typically appear after five years of dialysis therapy and often present as a triad of carpal tunnel syndrome, shoulder pain, and flexor tenosynovitis in the hands. The presence of all three symptoms in this patient strongly supports a diagnosis of dialysis amyloidosis.

      Other Possible Diagnoses

      Rheumatoid arthritis is a possible diagnosis due to joint pain and stiffness, but the absence of joint swelling makes it less likely. Diabetic neuropathy can cause sensory and motor neuropathies, but the joint symptoms in this patient do not support this diagnosis. Seronegative arthritis is unlikely due to the absence of joint swelling, and it doesn’t account for the neuropathic symptoms seen in this patient. Uraemic neuropathy is a distal sensorimotor polyneuropathy caused by uraemic toxins, but the presence of joint symptoms in this patient doesn’t support a diagnosis of neuropathy.

      Conclusion

      Based on the patient’s symptoms and medical history, dialysis amyloidosis is the most likely diagnosis. However, further testing and evaluation may be necessary to confirm this diagnosis and rule out other possible conditions.

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  • Question 76 - A 72-year-old man presents with complaints of erectile dysfunction. You suggest a trial...

    Incorrect

    • A 72-year-old man presents with complaints of erectile dysfunction. You suggest a trial of a phosphodiesterase inhibitor (such as sildenafil) after discussing his condition. What would be a contraindication to prescribing this medication?

      Your Answer:

      Correct Answer: Recent chest pain awaiting cardiology opinion

      Explanation:

      The use of PDE 5 inhibitors, such as sildenafil, is contraindicated in individuals who have recently experienced a myocardial infarction or unstable angina. However, in the case of someone experiencing chest pain and awaiting cardiology opinion, caution should also be exercised before prescribing these medications due to the potential cardiac nature of the symptoms. Additionally, patients with known angina who use a GTN spray should wait at least 24 hours after taking sildenafil or vardenafil, or 48 hours after taking tadalafil, to avoid the risk of excessive hypotension leading to a myocardial infarction.

      Phosphodiesterase type V inhibitors are medications used to treat erectile dysfunction and pulmonary hypertension. They work by increasing cGMP, which leads to relaxation of smooth muscles in blood vessels supplying the corpus cavernosum. The most well-known PDE5 inhibitor is sildenafil, also known as Viagra, which is taken about an hour before sexual activity. Other examples include tadalafil (Cialis) and vardenafil (Levitra), which have longer-lasting effects and can be taken regularly. However, these medications have contraindications, such as not being safe for patients taking nitrates or those with hypotension. They can also cause side effects such as visual disturbances, blue discolouration, and headaches. It is important to consult with a healthcare provider before taking PDE5 inhibitors.

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  • Question 77 - A 55-year-old man presents to the GP clinic with complaints of lower back...

    Incorrect

    • A 55-year-old man presents to the GP clinic with complaints of lower back pain, fevers, and weight loss. He has also noticed a weakened urinary stream and increased frequency of urination over the past six months. On examination, including digital rectal examination, there are no significant findings. The GP recommends that he see the practice phlebotomist to check his prostate serum antigen level. What is the most probable factor that could lead to a false positive result?

      Your Answer:

      Correct Answer: A confirmed UTI, successfully treated two weeks ago

      Explanation:

      Factors Affecting PSA Measurement

      Prostate serum antigen (PSA) measurement is a crucial screening tool for detecting prostate cancer. However, recent urinary tract infections can increase PSA levels, which may remain elevated for up to a month. There are several other factors that can influence PSA levels, including recent prostate biopsy, vigorous exercise within the last 48 hours, and ejaculation within the last 48 hours. It is recommended that men avoid PSA testing under these circumstances. On the other hand, there is no evidence to suggest that an intercurrent illness, such as an upper respiratory tract infection, affects PSA levels. Proper understanding of these factors can help ensure accurate PSA measurement and reliable prostate cancer detection.

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  • Question 78 - A 67-year-old man has been referred under the 2-week rule due to frank...

    Incorrect

    • A 67-year-old man has been referred under the 2-week rule due to frank haematuria. He underwent a flexible cystoscopy and biopsies, which revealed a small superficial bladder tumour. He is a non-smoker. What is the most suitable advice you can give this patient regarding his bladder tumour?

      Your Answer:

      Correct Answer: The majority of tumours involve only the urothelium and are non-invasive

      Explanation:

      Bladder Cancer: Facts and Figures

      Bladder cancer is a type of cancer that affects the bladder, a hollow organ in the pelvis that stores urine. Here are some important facts and figures about bladder cancer:

      – The majority of bladder tumours involve only the urothelium (the lining of the bladder) and are non-invasive.
      – Transitional-cell tumours account for 90% of bladder cancers in the UK. About 70% of patients have superficial disease at diagnosis.
      – The 5-year survival rate for bladder cancer is typically less than 50%. However, patients with superficial tumours have a 5-year survival rate of 80-90%, while those with muscle-invasive tumours have a rate as low as 30-60%.
      – Although smoking is a risk factor for bladder cancer, it is linked to only about 50% of cases, meaning that it is still common in non-smokers.
      – Most non-invasive bladder tumours are managed with transurethral resection of the bladder tumour (TURBT). Radical cystectomy (removal of the bladder) may be necessary for invasive tumours.
      – The most common symptom of bladder cancer is painless haematuria (blood in the urine). Voiding symptoms are more likely to occur in advanced disease.

      Bladder cancer is a serious condition that requires prompt diagnosis and treatment. If you experience any symptoms of bladder cancer, such as blood in the urine or changes in urination patterns, you should see a doctor right away.

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  • Question 79 - A 55-year-old man with a history of chronic kidney disease (CKD) has transferred...

    Incorrect

    • A 55-year-old man with a history of chronic kidney disease (CKD) has transferred to the surgery. He is reviewed in clinic and it is noted that his vaccination history is not up to date. The patient's renal disease is advanced and he says that his renal specialist has been discussing the potential for haemodialysis and eventually transplantation.
      Which of the following is the most appropriate vaccination regimen for this patient?

      Your Answer:

      Correct Answer: Hepatitis B, influenza and pneumococcal

      Explanation:

      Vaccination Recommendations for Patients with Chronic Kidney Disease

      Patients with chronic kidney disease (CKD) are at increased risk of infections due to their compromised immune system. Vaccination is an important preventive measure for these patients. The following vaccines are recommended for patients with CKD:

      Hepatitis B, influenza, and Pneumococcal Vaccines
      Patients on Renal Replacement Therapy (RRT) or those likely to require RRT in the future should receive the standard series of three doses of hepatitis B vaccine. influenza vaccine should be given annually to all patients with CKD. Patients with CKD 3 or above should be offered two doses of Pneumococcal Conjugate Vaccine (PCV) two months apart, followed by a booster dose of PCV every five years.

      Hepatitis A and Hepatitis B Vaccine
      Patients with haemophilia should receive the combination of Hepatitis A and Hepatitis B vaccine.

      Hib MenC, Men B Pneumococcal Vaccine
      Patients with a defective spleen, such as those with sickle cell disease or those who have had or will require splenectomy, should receive this combination vaccine.

      influenza and Pneumococcal and BCG Vaccine
      The BCG vaccine is not recommended for patients with CKD unless they are at increased risk of tuberculosis.

      It is important to note that immunisation should be given early in the course of progressive renal disease to maximise the chance of immunity. Live vaccines may need to be deferred in severely immunocompromised patients, but the majority of patients with CKD have sufficient immune function to safely receive live vaccines if there is no inactivated form available. Patients should also be monitored for antibody levels and offered booster doses as necessary.

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  • Question 80 - A 57-year-old man with type-2 diabetes had a serum creatinine concentration of 250...

    Incorrect

    • A 57-year-old man with type-2 diabetes had a serum creatinine concentration of 250 µmol/l (50-110) before admission to hospital for radiographic investigation including intravenous contrast medium visualisation. Two days after discharge home his creatinine concentration is now 470 µmol/l and he has only passed small amounts of urine.
      Select from the list the single most correct option.

      Your Answer:

      Correct Answer: He has acute tubular necrosis

      Explanation:

      Acute kidney injury (AKI) is diagnosed through decreased glomerular filtration rate (GFR), increased serum creatinine or cystatin C, or oliguria. AKI is categorized into prerenal, renal, and postrenal. Prerenal AKI occurs when a normally functioning kidney responds to hypoperfusion by decreasing the GFR. Renal AKI refers to a condition where the pathology lies within the kidney itself. Postrenal failure is caused by an obstruction of the urinary tract. The most common cause of AKI in the renal category is acute tubular necrosis (ATN), which is usually due to prolonged ischaemia or nephrotoxins. Contrast-induced nephropathy (CIN) is defined as a significant increase in serum creatinine after a radiographic examination using a contrast agent. Preexisting renal insufficiency, preexisting diabetes, and reduced intravascular volume are associated with an increased risk of CIN. Adequate hydration is an important preventative measure. In most cases, renal function returns to normal within 7-14 days of contrast administration. Dialysis is required in less than 1% of patients, with a slightly higher incidence in patients with underlying renal impairment and in those undergoing primary coronary intervention for myocardial infarction. However, in patients with diabetes and pre-existing severe renal failure, the rate of dialysis can be as high as 12%.

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  • Question 81 - A 65-year-old woman presents with dysuria, frequency of urination, and suprapubic discomfort. Urine...

    Incorrect

    • A 65-year-old woman presents with dysuria, frequency of urination, and suprapubic discomfort. Urine dipstick testing shows:
      nitrites+
      leucocytes++
      blood++

      She has had four urinary tract infections in the last six months, with each episode confirmed by laboratory testing. On each occasion, urine dipstick testing has shown microscopic blood as well as nitrite and leucocyte positivity. After treatment with antibiotics, the infections have settled, but on the last occasion, she experienced visible haematuria.

      The patient asks if there is anything she can do to prevent these infections. She had only one previous UTI about six years ago. What is the best approach in this case?

      Your Answer:

      Correct Answer: Refer her to a urologist as urgent suspected cancer at this point in time

      Explanation:

      Referral Guidelines for Recurrent UTI with Non-Visible Haematuria

      Recurrent UTI is defined as three or more episodes in a year. In the case of a woman with her fourth episode in the last six months, it is important to investigate further. If visible or non-visible haematuria is present on dipstick testing when a UTI is suspected, a urine sample should be sent to the laboratory for mc+s testing in all patients. If infection is confirmed, a urine sample should be dipstick tested for blood after antibiotic treatment has been completed. If haematuria persists, further investigation is warranted.

      According to NICE guidelines, urgent referral is necessary for bladder cancer if a person aged 45 and over has unexplained visible haematuria without urinary tract infection or visible haematuria that persists or recurs after successful treatment of urinary tract infection. For renal cancer, urgent referral is necessary if a person aged 45 and over has unexplained visible haematuria without urinary tract infection or visible haematuria that persists or recurs after successful treatment of urinary tract infection.

      In the case of a woman with recurrent UTIs associated with non-visible haematuria each time, urgent referral to a urologist is necessary. It is important to follow these guidelines to ensure timely diagnosis and treatment of potential cancer.

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  • Question 82 - You see a 30-year-old gentleman who is being investigated for subfertility. His semen...

    Incorrect

    • 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:

      Correct 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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  • Question 83 - A 30-year-old man presents to the General Practitioner complaining of severe pain in...

    Incorrect

    • A 30-year-old man presents to the General Practitioner complaining of severe pain in the left flank and left lower abdomen with radiation to the left testicle. He reports that he woke up with the pain, but was “fine last night”. The clinician suspects uncomplicated renal colic.
      What feature would best support this diagnosis in this patient?

      Your Answer:

      Correct Answer: Haematuria

      Explanation:

      Understanding the Symptoms of Renal Colic

      Renal colic is a condition characterized by sudden and severe pain caused by stones in the urinary tract. The pain typically starts in the loin and moves to the groin, with tenderness in the renal angle. Patients with renal colic may experience periods of relief or dull aches before the pain returns. Other symptoms include microscopic haematuria, nausea, and vomiting. Unlike patients with peritoneal irritation, those with renal colic may writhe around in agony and have increased bowel sounds. Apyrexia is common in uncomplicated cases, while pyrexia suggests infection. It’s important to note that although there may be severe pain in the testis, the testis itself should not be tender. Understanding these symptoms can help with the diagnosis and management of renal colic.

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  • Question 84 - A 68-year-old man with stable chronic renal impairment has routine blood tests and...

    Incorrect

    • A 68-year-old man with stable chronic renal impairment has routine blood tests and urine testing for proteinuria. The results show an estimated glomerular filtration rate (eGFR) of 42 ml/min/1.73m2 and an albumin : creatinine ratio (ACR) of 1.3 mg/mmol.
      According to NICE guidance, select the optimal clinical blood pressure in this patient.

      Your Answer:

      Correct Answer:

      Explanation:

      Managing Blood Pressure in Chronic Kidney Disease Patients

      According to NICE guidance, patients with chronic kidney disease should aim for a target blood pressure of 140/90 mmHg or less if they do not have proteinuria. However, if they have an albumin : creatinine ratio (ACR) of 70 mg/mmol or more, the target should be 130/80 mmHg or less.

      For those with chronic kidney disease and diabetes with an ACR of 3 mg/mmol or more, or hypertension with an ACR of 30 mg/mmol or more, or an ACR of 70 mg/mmol or more (regardless of hypertension or cardiovascular disease), an angiotensin-converting enzyme inhibitor or angiotensin-II receptor antagonist should be used.

      It is important to note that microalbuminuria is defined as an ACR > 2.5 mg/mmol (men) or > 3.5 mg/mmol (women), while proteinuria is defined as an ACR > 30 mg/mmol. Without knowing if the patient is hypertensive, it is unclear if they meet the criteria for medication use. Proper management of blood pressure is crucial in the care of patients with chronic kidney disease.

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  • Question 85 - You see a 70-year-old patient with diabetes, hypertension, and chronic kidney disease (CKD)....

    Incorrect

    • You see a 70-year-old patient with diabetes, hypertension, and chronic kidney disease (CKD). He had an anterior myocardial infarction (MI) 2 months ago for which he had a stent. He is having his annual review when he mentions that he has suffered from erectile dysfunction for the last 2 years. He says that it came on gradually and that he now never has erections anymore, in any situation. He has been married for 45 years and this is having an effect on his relationship with his wife.

      His blood pressure today is 135/85 mmHg. Recent blood tests reveal that his blood glucose levels are well controlled on oral medications and his CKD is stable. He takes regular exercise.

      What is the recommended first-line treatment for this patient's erectile dysfunction?

      Your Answer:

      Correct Answer: A vacuum erection device along with lifestyle advice

      Explanation:

      The NICE clinical knowledge summary (CKS) guidelines recommend phosphodiesterase (PDE-5) inhibitors, such as sildenafil and tadalafil, as the first-line treatment for erectile dysfunction (ED) unless there are contraindications. However, those who cannot or will not take PDE-5 inhibitors may benefit from vacuum erection devices, which are recommended as the first-line treatment for well-informed older men with infrequent sexual intercourse and comorbidity requiring non-invasive, drug-free management of ED. Lifestyle changes and risk factor modification should also be considered, but this patient already has good control of his risk factors and regularly exercises. Intracavernous injections may be a second-line option for men with pelvic trauma or spinal cord injury. Vasculogenic causes, such as cardiovascular disease, are the most common organic cause of ED, and lifestyle changes and drug treatment can be effective in managing this condition.

      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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  • Question 86 - A 65-year-old male patient presents with recurrent urinary symptoms, reporting bothersome hesitancy and...

    Incorrect

    • A 65-year-old male patient presents with recurrent urinary symptoms, reporting bothersome hesitancy and nocturia. He is currently taking finasteride.
      PSA levels over the past two months have been within normal range for his age, measuring at 3.2 and 3.3 ng/ml. Upon physical examination, including a digital rectal exam, no abnormalities were detected.
      What is the appropriate course of action at this juncture?

      Your Answer:

      Correct Answer: Stop the finasteride and repeat the PSA in six weeks

      Explanation:

      Importance of Checking for Prostate Cancer in Patients on Finasteride

      Whilst other possibilities should not be disregarded, it is crucial to prioritize checking for prostate cancer in patients taking Finasteride. It is important to note that PSA values may be significantly reduced by up to 50% in patients taking 5-ARIs such as Finasteride, which can bring abnormal prostates into the normal range in terms of PSA values. Additionally, any increase in PSA levels should be a cause for concern, even if the absolute value is within the normal range, when a patient is taking Finasteride. It is essential to double the PSA readings of patients on Finasteride, which means that the corrected values for this patient are 6.2 and 6.0 ng/ml. Therefore, it is crucial to prioritize checking for prostate cancer in patients taking Finasteride to ensure timely diagnosis and treatment.

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  • Question 87 - Sophie is a 70-year-old woman who has recently been diagnosed with chronic kidney...

    Incorrect

    • Sophie is a 70-year-old woman who has recently been diagnosed with chronic kidney disease secondary to hypertension. She has come to see her GP for a review. On examination her blood pressure is 140/85 mmHg. She has no other past medical history of note. Her recent investigation results are as follows:

      Hb 130g/L Female: (120-160)
      Na+ 142 mmol/L (135 - 145)
      K+ 4.5 mmol/L (3.5 - 5.0)
      Urea 7.8 mmol/L (2.0 - 7.0)
      Creatinine 135 µmol/L (55 - 120)
      eGFR 60mL/min/1.73m2 (>90 mL/min/1.73m2)
      Urine albumin:Creatinine ratio 30 mg/mmol (<3mg/mmol)
      HbA1c 42 mmol/mol (<42 mmol/mol)

      She currently takes lisinopril, atorvastatin and ferrous sulphate.

      What additional medication should she be prescribed?

      Your Answer:

      Correct Answer: Ramipril

      Explanation:

      Patients with chronic kidney disease and an albumin:creatinine ratio (ACR) of more than 3 mg/mmol should be prescribed an ACE inhibitor. If co-existent diabetes is present, an ACE inhibitor should be prescribed regardless of ACR. If co-existent hypertension is present, an ACE inhibitor should be prescribed if ACR is >30 mg/mmol. If ACR is >70mg/mmol, an ACE inhibitor should also be prescribed. Therefore, ramipril is the appropriate medication. Bendroflumethiazide should be avoided as it may exacerbate renal failure. Aspirin may be used for secondary prevention of cardiovascular disease in accordance with guidelines, but not for primary prevention.

      Proteinuria in Chronic Kidney Disease: Diagnosis and Management

      Proteinuria is a significant indicator of chronic kidney disease, particularly in cases of diabetic nephropathy. The National Institute for Health and Care Excellence (NICE) recommends using the albumin:creatinine ratio (ACR) over the protein:creatinine ratio (PCR) for identifying patients with proteinuria due to its higher sensitivity. PCR can be used for quantification and monitoring of proteinuria, but ACR is preferred for diabetics. Urine reagent strips are not recommended unless they express the result as an ACR.

      To collect an ACR sample, a first-pass morning urine specimen is preferred as it avoids the need to collect urine over a 24-hour period. If the initial ACR is between 3 mg/mmol and 70 mg/mmol, a subsequent early morning sample should confirm it. However, if the initial ACR is 70 mg/mmol or more, a repeat sample is unnecessary.

      According to NICE guidelines, a confirmed ACR of 3 mg/mmol or more is considered clinically important proteinuria. Referral to a nephrologist is recommended for patients with a urinary ACR of 70 mg/mmol or more, unless it is known to be caused by diabetes and already appropriately treated. Referral is also necessary for patients with an ACR of 30 mg/mmol or more, along with persistent haematuria after exclusion of a urinary tract infection. For patients with an ACR between 3-29 mg/mmol and persistent haematuria, referral to a nephrologist is considered if they have other risk factors such as declining eGFR or cardiovascular disease.

      The frequency of monitoring eGFR varies depending on the eGFR and ACR categories. ACE inhibitors or angiotensin II receptor blockers are key in managing proteinuria and should be used first-line in patients with coexistent hypertension and CKD if the ACR is > 30 mg/mmol. If the ACR is > 70 mg/mmol, they are indicated regardless of the patient’s blood pressure.

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  • Question 88 - Which one of the following statements regarding the assessment of proteinuria in elderly...

    Incorrect

    • Which one of the following statements regarding the assessment of proteinuria in elderly patients with chronic kidney disease is incorrect?

      Your Answer:

      Correct Answer: An ACR sample is collected over 24 hours

      Explanation:

      Proteinuria in Chronic Kidney Disease: Diagnosis and Management

      Proteinuria is a significant indicator of chronic kidney disease, particularly in cases of diabetic nephropathy. The National Institute for Health and Care Excellence (NICE) recommends using the albumin:creatinine ratio (ACR) over the protein:creatinine ratio (PCR) for identifying patients with proteinuria due to its higher sensitivity. PCR can be used for quantification and monitoring of proteinuria, but ACR is preferred for diabetics. Urine reagent strips are not recommended unless they express the result as an ACR.

      To collect an ACR sample, a first-pass morning urine specimen is preferred as it avoids the need to collect urine over a 24-hour period. If the initial ACR is between 3 mg/mmol and 70 mg/mmol, a subsequent early morning sample should confirm it. However, if the initial ACR is 70 mg/mmol or more, a repeat sample is unnecessary.

      According to NICE guidelines, a confirmed ACR of 3 mg/mmol or more is considered clinically important proteinuria. Referral to a nephrologist is recommended for patients with a urinary ACR of 70 mg/mmol or more, unless it is known to be caused by diabetes and already appropriately treated. Referral is also necessary for patients with an ACR of 30 mg/mmol or more, along with persistent haematuria after exclusion of a urinary tract infection. For patients with an ACR between 3-29 mg/mmol and persistent haematuria, referral to a nephrologist is considered if they have other risk factors such as declining eGFR or cardiovascular disease.

      The frequency of monitoring eGFR varies depending on the eGFR and ACR categories. ACE inhibitors or angiotensin II receptor blockers are key in managing proteinuria and should be used first-line in patients with coexistent hypertension and CKD if the ACR is > 30 mg/mmol. If the ACR is > 70 mg/mmol, they are indicated regardless of the patient’s blood pressure.

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  • Question 89 - You are working in a GP surgery when you have been asked to...

    Incorrect

    • You are working in a GP surgery when you have been asked to review a urine result of a 26-year-old woman who is currently 12 weeks pregnant. The urine sample was collected during her recent appointment with her midwife and the result has returned showing the presence of Escherichia coli. You speak to the patient on the phone to discuss the results and learn that she is well with no history of urinary symptom, abdominal pain or temperature.

      What is the most suitable course of action for managing this patient's condition?

      Your Answer:

      Correct Answer: Antibiotic prescription for 7 days

      Explanation:

      The immediate treatment of antibiotics is recommended for pregnant women with asymptomatic bacteriuria. This condition is prevalent and poses a risk for pyelonephritis, premature delivery, and low birth weight, according to NICE guidelines. Treatment for seven days is currently advised. Escherichia coli, which can cause urinary tract infections and gastroenteritis, is a pathogenic organism.

      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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  • Question 90 - Which of the following is the least acknowledged side effect of consuming bendroflumethiazide?...

    Incorrect

    • Which of the following is the least acknowledged side effect of consuming bendroflumethiazide?

      Your Answer:

      Correct Answer: Pseudogout

      Explanation:

      Gout is more likely to occur as a result of taking bendroflumethiazide, rather than pseudogout.

      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 thiazide diuretics are useful in treating mild heart failure, loop diuretics are more effective in reducing overload. Bendroflumethiazide was previously used to manage hypertension, but recent NICE guidelines recommend other thiazide-like diuretics such as indapamide and chlortalidone.

      Common side effects of thiazide diuretics include dehydration, postural hypotension, and electrolyte imbalances such as hyponatremia, hypokalemia, and hypercalcemia. Other potential adverse effects include gout, impaired glucose tolerance, and impotence. Rare side effects may include thrombocytopenia, agranulocytosis, photosensitivity rash, and pancreatitis.

      It is worth noting that while thiazide diuretics may cause hypercalcemia, they can also reduce the incidence of renal stones by decreasing urinary calcium excretion. According to current NICE guidelines, the management of hypertension involves the use of thiazide-like diuretics, along with other medications and lifestyle changes, to achieve optimal blood pressure control and reduce the risk of cardiovascular disease.

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  • Question 91 - A 63-year-old man, John, reports that his older brother has just been diagnosed...

    Incorrect

    • A 63-year-old man, John, reports that his older brother has just been diagnosed with prostate cancer after having his PSA test done as part of the national screening programme. John says that he has had his PSA test today and the results were normal.

      When will John's next PSA test be due?

      Your Answer:

      Correct Answer: 3 years

      Explanation:

      In the UK, breast cancer screening is currently offered to women between the ages of 50 and 70 every three years. However, there are plans to expand this service to include women aged 47 to 73 by the end of 2016. Additionally, women between the ages of 40 and 50 who are at a high risk of developing breast cancer may be offered screening every two years.

      Breast Cancer Screening and Familial Risk Factors

      Breast cancer screening is offered to women aged 50-70 years through the NHS Breast Screening Programme, with mammograms offered every three years. While the effectiveness of breast screening is debated, it is estimated that the programme saves around 1,400 lives annually. Women over 70 years may still have mammograms but are encouraged to make their own appointments.

      For those with familial risk factors, NICE guidelines recommend referral to a breast clinic for further assessment. Those with one first-degree or second-degree relative diagnosed with breast cancer do not need referral unless certain factors are present in the family history, such as early age of diagnosis, bilateral breast cancer, male breast cancer, ovarian cancer, Jewish ancestry, or complicated patterns of multiple cancers at a young age. Women with an increased risk of breast cancer due to family history may be offered screening from a younger age.

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  • Question 92 - A 28-year-old man with a history of hypertension and intermittent loin pain presents...

    Incorrect

    • A 28-year-old man with a history of hypertension and intermittent loin pain presents to his new GP for registration after moving house. During urine testing, evidence of haematuria is found. The patient has a family history of subarachnoid haemorrhage.
      What is the most likely diagnosis based on this clinical presentation?

      Your Answer:

      Correct Answer: Autosomal-dominant polycystic kidney disease

      Explanation:

      Understanding Common Kidney Conditions: ADPKD, Glomerulonephritis, Renal Stones, Renal Cell Carcinoma, and Urinary Tract Infection

      The kidneys are vital organs responsible for filtering waste products from the blood and regulating fluid balance in the body. However, they can be affected by various conditions that can lead to significant health problems. Here are some common kidney conditions and their characteristics:

      Autosomal Dominant Polycystic Kidney Disease (ADPKD)
      ADPKD is a genetic disorder that causes the growth of multiple cysts in the kidneys, leading to kidney enlargement and dysfunction. Symptoms may include hypertension, painless haematuria, intermittent loin pain, and a family history of subarachnoid haemorrhage. ACE inhibitors are the first-line treatment for hypertension in ADPKD patients.

      Glomerulonephritis
      Glomerulonephritis is a group of immune-mediated disorders that cause inflammation within the glomerulus and other parts of the kidney. It can present with a range of symptoms, from asymptomatic urinary abnormalities to the nephritic and nephrotic syndromes.

      Renal Stones
      Renal stones are hard deposits that form in the kidneys and can cause sudden severe renal colic. They may be asymptomatic and discovered during investigations for other conditions.

      Renal Cell Carcinoma
      Renal cell carcinoma is a type of kidney cancer that can be detected using ultrasound and CT scans. More than half of adult renal tumours are detected when using ultrasound to investigate nonspecific symptoms. The classic features of haematuria, loin pain, and loin mass are not as frequently seen now.

      Urinary Tract Infection
      Urinary tract infection is a common condition that presents acutely. It occurs when bacteria enter the urinary tract and cause inflammation and infection. Symptoms may include pain or burning during urination, frequent urination, and cloudy or bloody urine.

      In conclusion, understanding the characteristics of common kidney conditions can help with early detection and appropriate management, leading to better outcomes for patients.

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  • Question 93 - A patient with chronic kidney disease stage 3 is prescribed lisinopril. After two...

    Incorrect

    • A patient with chronic kidney disease stage 3 is prescribed lisinopril. After two weeks, blood tests are conducted and no other medication changes have been made. The patient is examined and found to be adequately hydrated. As per NICE guidelines, what is the maximum acceptable rise in creatinine levels after initiating an ACE inhibitor?

      Your Answer:

      Correct Answer: 30%

      Explanation:

      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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  • Question 94 - A 50-year-old man comes to his General Practitioner complaining of recurrent loin-to-groin pain...

    Incorrect

    • A 50-year-old man comes to his General Practitioner complaining of recurrent loin-to-groin pain and frank haematuria. A CT scan of his KUB shows a renal calculus located at the left vesico-ureteric junction. What is the most accurate understanding of this man's condition?

      Your Answer:

      Correct Answer: Recurrent proteus urinary tract infections (UTIs) are associated with renal calculi

      Explanation:

      Understanding Renal Calculi and Recurrent Proteus Urinary Tract Infections

      Recurrent Proteus urinary tract infections (UTIs) are often associated with renal calculi, which can be detected through persistently alkaline urine and a finding of Proteus on culture. This is because Proteus organisms produce urease, which converts urea into ammonia and alkalinizes the urine, leading to the formation of organic and inorganic compounds that contribute to calculi formation.

      The severity of symptoms related to renal calculi is directly proportional to the size of the stone. Smaller stones usually cause severe pain as they pass into the ureter, while larger stones such as staghorn calculi often remain asymptomatic in the kidney. A moving stone is usually more painful than a static stone.

      Contrary to popular belief, most symptomatic urinary calculi originate in the upper renal tract, with the location and composition varying for different types of stones. While gallstones are composed of bile salts, renal stones are usually composed of calcium, oxalate, or uric acid.

      About 75% of renal calculi are radio-opaque, meaning they can be detected through conventional KUB X-rays. However, urate and xanthine stones are radiolucent and may be too small to be detected through this method. Understanding the relationship between recurrent Proteus UTIs and renal calculi can help prompt early detection and treatment.

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  • Question 95 - A 55-year-old Asian man who has lived in the United Kingdom for the...

    Incorrect

    • A 55-year-old Asian man who has lived in the United Kingdom for the past 10 years presents with painless haematuria. He is a smoker of 10 cigarettes per day.

      Investigations reveal a haemoglobin of 110 g/L (120-160), urinalysis shows ++ blood and PA chest x ray shows small flecks of white opacifications in the upper lobe of the left lung.

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Bladder carcinoma

      Explanation:

      Diagnosis and Risk Factors for Haematuria and Anaemia in a Middle-Aged Male

      The most likely diagnosis for a middle-aged male presenting with haematuria and anaemia is carcinoma of the bladder. This is supported by the patient’s history of smoking, which is a known risk factor for bladder cancer. Although renal TB is a possibility, the absence of systemic symptoms such as fever, night sweats, and weight loss makes it less likely. The opacifications in the lung are consistent with previous primary TB. It is important to note that renal TB can present without systemic symptoms, but bladder cancer is more common in this scenario. Proper diagnosis and management are crucial in cases of haematuria and anaemia, and further investigations should be carried out to confirm the diagnosis and determine the appropriate treatment plan.

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  • Question 96 - You are seeing a 65-year-old man who has come to discuss PSA testing....

    Incorrect

    • You are seeing a 65-year-old man who has come to discuss PSA testing. He plays tennis once a week with a friend who is on medication for his 'waterworks' and has had his PSA tested. He has come as he is not sure whether he would benefit from a PSA test.

      He is otherwise well with no specific urinary tract/genitourinary signs or symptoms. He has no significant past medical history or family history.

      Which of the following is appropriate advice to give regarding PSA testing?

      Your Answer:

      Correct Answer: For every 25 men identified with prostate cancer following a high PSA test result, subsequent treatment will save one life

      Explanation:

      PSA Testing for Prostate Cancer Screening: Understanding the Limitations

      PSA testing for prostate cancer screening is a topic of debate among medical professionals. While some advocate for its use, others are wary of over-treatment and patient harm. One of the main concerns is the limitations of PSA testing in terms of its sensitivity and specificity.

      When counseling men about PSA testing, it is important to provide them with understandable statistics and facts. For instance, two-thirds of men with a raised PSA will not have prostate cancer, while 15 out of 100 with a negative PSA will have prostate cancer. Additionally, PSA testing cannot distinguish between slow- and fast-growing cancers, and many men may have slow-growing cancers that would not have impacted their life expectancy if left undiscovered.

      Another point of debate is the frequency of PSA testing. While some patients opt for annual testing, experts suggest that a normal PSA in an asymptomatic man doesn’t need to be repeated for at least two years.

      When it comes to prostate cancer treatment, approximately 48 men need to undergo treatment in order to save one life. Overall, it is important to understand the limitations of PSA testing and to weigh the potential benefits and risks before making a decision about screening.

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  • Question 97 - A 12-year-old boy visits his GP with his mother after he observed blood...

    Incorrect

    • A 12-year-old boy visits his GP with his mother after he observed blood in his urine two days after receiving treatment for tonsillitis. Upon conducting a urine dipstick test, it is positive for blood and protein. The doctor sends a sample for microscopy, culture, and sensitivity and receives the following results: Growth < 104 cfu/ml, Large numbers of red blood cells, < 10/mm3 of white blood cells, and red-cell casts in microscopy. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Glomerulonephritis

      Explanation:

      Differentiating Causes of Haematuria: A Brief Overview

      Haematuria, or the presence of blood in the urine, can be caused by a variety of conditions. One possible cause is glomerulonephritis, which is indicated by the presence of red-cell casts in the urine. In particular, post-streptococcal glomerulonephritis (PSGN) may be suspected if the patient has a recent history of tonsillitis. PSGN typically resolves on its own, but symptom control and infection removal may be necessary.

      Another possible cause of haematuria is myoglobinuria, which is characterized by a positive urine dipstick but the absence of red-cell casts. Myoglobinuria is an early sign of rhabdomyolysis, which requires fluid resuscitation and further investigations into renal function and creatine kinase.

      Porphyria, on the other hand, may cause dark or reddish urine due to excessive excretion of haem precursors. However, red-cell casts are not present and a urine dipstick would not be positive for blood.

      Renal calculus, or kidney stones, is unlikely in a young patient and would typically be accompanied by severe pain. No casts would be present in this case.

      Finally, a urinary tract infection (UTI) may cause haematuria, but a diagnosis requires significant bacteriuria, which is defined as greater than 100,000 colonies of bacteria per milliliter of urine. Counts between 10,000 and 100,000 are indeterminate, while counts below 10,000 are considered normal. Sensitivity testing may be necessary to determine the appropriate antibiotics for treatment.

      In summary, the presence of red-cell casts in the urine suggests glomerulonephritis, while a positive urine dipstick without casts may indicate myoglobinuria. Other possible causes of haematuria include porphyria, renal calculus, and UTI, but these require further investigation and testing for diagnosis.

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  • Question 98 - You assess a 60-year-old man who is undergoing surgery. He has been diagnosed...

    Incorrect

    • You assess a 60-year-old man who is undergoing surgery. He has been diagnosed with benign prostatic hypertrophy for 3 years and is currently taking tamsulosin and finasteride to manage his symptoms. However, he has been experiencing worsening symptoms of poor flow, hesitancy, nocturia, weight loss, and back pain for the past 2 months. You order a prostate-specific antigen test, which returns a result of 2.5ng/mL - within the normal range for his age. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Prostate cancer

      Explanation:

      The patient is most likely suffering from prostate cancer. Despite having well-controlled BPH with medication, he has developed new lower urinary tract symptoms along with red flag features such as weight loss and back pain. Although his PSA levels are normal, it should be noted that he is taking finasteride which can lower PSA levels. The duration of symptoms and weight loss over a period of 3 months are not indicative of a urinary tract infection. It is also unlikely that the patient is suffering from treatment-resistant BPH after successfully managing the condition for 5 years. While spinal cord compression can cause urinary symptoms, it is unlikely to cause nocturia or flow issues.

      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. Ethnicity also plays a role, with black men having a higher risk than white or Asian men. BPH typically presents with lower urinary tract symptoms (LUTS), which can be categorised into obstructive (voiding) symptoms and irritative (storage) symptoms. Complications of BPH can include urinary tract infections, retention, and obstructive uropathy.

      Assessment of BPH may involve dipstick urine testing, U&Es, and PSA testing if obstructive symptoms are present or if the patient is concerned about prostate cancer. 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 for moderate-to-severe voiding symptoms and can improve symptoms in around 70% of men, but may cause adverse effects such as dizziness and dry mouth. 5 alpha-reductase inhibitors may slow disease progression and reduce prostate volume, but can cause adverse effects such as erectile dysfunction and reduced libido. Combination therapy may be used for bothersome moderate-to-severe voiding symptoms and prostatic enlargement. Antimuscarinic drugs may be tried for persistent storage symptoms. Surgery, such as transurethral resection of the prostate (TURP), may also be an option.

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  • Question 99 - A 60-year-old man with a history of type 2 diabetes mellitus and benign...

    Incorrect

    • A 60-year-old man with a history of type 2 diabetes mellitus and benign prostatic hypertrophy experiences urinary retention and an acute kidney injury. Which medication should be discontinued?

      Your Answer:

      Correct Answer: Metformin

      Explanation:

      Due to the risk of lactic acidosis, metformin should be discontinued as the patient has developed an acute kidney injury. Additionally, in the future, it may be necessary to discontinue paroxetine as SSRIs can exacerbate urinary retention.

      Metformin is a medication commonly used to treat type 2 diabetes mellitus, as well as polycystic ovarian syndrome and non-alcoholic fatty liver disease. Unlike other medications, such as sulphonylureas, metformin doesn’t cause hypoglycaemia or weight gain, making it a first-line treatment option, especially for overweight patients. Its mechanism of action involves activating the AMP-activated protein kinase, increasing insulin sensitivity, decreasing hepatic gluconeogenesis, and potentially reducing gastrointestinal absorption of carbohydrates. However, metformin can cause gastrointestinal upsets, reduced vitamin B12 absorption, and in rare cases, lactic acidosis, particularly in patients with severe liver disease or renal failure. It is contraindicated in patients with chronic kidney disease, recent myocardial infarction, sepsis, acute kidney injury, severe dehydration, and those undergoing iodine-containing x-ray contrast media procedures. When starting metformin, it should be titrated up slowly to reduce the incidence of gastrointestinal side-effects, and modified-release metformin can be considered for patients who experience unacceptable side-effects.

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  • Question 100 - A 50-year-old man presents to the emergency department with a 48-hour history of...

    Incorrect

    • A 50-year-old man presents to the emergency department with a 48-hour history of dysuria and visible blood in his urine. He also reports some frequency of urination. However, he denies fever, abdominal pain, or loin pain. He mentions that his urine has gradually cleared up since it was like red wine 48 hours ago and now looks normal. On examination, he appears to be in good health with no fever. His pulse rate is 76 bpm regular, and his blood pressure is 138/76 mmHg. His abdomen and loins are normal to palpation. A urine sample is taken, which appears macroscopically normal, but dipstick testing reveals leucocytes ++ and blood+++. You prescribe antibiotics to cover a urinary tract infection. What is the most appropriate next step in managing this patient?

      Your Answer:

      Correct Answer: Request an urgent CT urogram to rule out a renal calculi

      Explanation:

      Referral for Suspected Bladder Cancer

      According to NICE guidelines, individuals with certain symptoms should be referred for suspected cancer pathway referral within 2 weeks. For bladder cancer, this includes individuals aged 45 and over with unexplained visible haematuria or visible haematuria that persists or recurs after successful treatment of urinary tract infection. It also includes individuals aged 60 and over with unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test.

      However, before referral, it is important to establish whether there is a urinary tract infection present. If there is, appropriate treatment can be given and referral for further investigation into the haematuria may not be necessary. In cases where there are symptoms suggestive of a urinary infection and macroscopic haematuria, investigations should be undertaken to diagnose and treat the infection before considering referral. If infection is not confirmed, urgent referral is warranted to investigate the haematuria further.

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  • Question 101 - A 60-year-old man complains of nocturia, hesitancy, and terminal dribbling. During prostate examination,...

    Incorrect

    • A 60-year-old man complains of nocturia, hesitancy, and terminal dribbling. During prostate examination, a moderately enlarged prostate with no irregular features and a well-defined median sulcus is observed. His 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. Ethnicity also plays a role, with black men having a higher risk than white or Asian men. BPH typically presents with lower urinary tract symptoms (LUTS), which can be categorised into obstructive (voiding) symptoms and irritative (storage) symptoms. Complications of BPH can include urinary tract infections, retention, and obstructive uropathy.

      Assessment of BPH may involve dipstick urine testing, U&Es, and PSA testing if obstructive symptoms are present or if the patient is concerned about prostate cancer. 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 for moderate-to-severe voiding symptoms and can improve symptoms in around 70% of men, but may cause adverse effects such as dizziness and dry mouth. 5 alpha-reductase inhibitors may slow disease progression and reduce prostate volume, but can cause adverse effects such as erectile dysfunction and reduced libido. Combination therapy may be used for bothersome moderate-to-severe voiding symptoms and prostatic enlargement. Antimuscarinic drugs may be tried for persistent storage symptoms. Surgery, such as transurethral resection of the prostate (TURP), may also be an option.

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  • Question 102 - A 49-year-old patient sees you as part of a health check-up.
    He asks you...

    Incorrect

    • A 49-year-old patient sees you as part of a health check-up.
      He asks you your views about whether he should have a PSA (prostate-specific antigen) check.

      Your Answer:

      Correct Answer: The patient should be dissuaded from a PSA check as there is no evidence that screening for prostate cancer improves mortality rates from the disease

      Explanation:

      PSA Testing and Prostate Cancer Screening

      Current advice from the Department of Health states that patients should not be refused a PSA test if they request one. However, patients should be informed about the implications of the test. While there is no clear evidence to support mass prostate cancer screening, studies have shown that diagnosing patients through case presentation has led to improved cancer mortality rates in the USA. It is important to note that many patients with prostate cancer do not experience symptoms, and urinary symptoms are not always indicative of the disease. Additionally, prostate cancer can develop in patients as young as their fifth decade of life.

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  • Question 103 - A 74-year-old man presents to the General Practitioner with complaints of penile pain....

    Incorrect

    • A 74-year-old man presents to the General Practitioner with complaints of penile pain. He has an indwelling catheter that has recently been changed. During examination, the preputial skin is retracted, swollen and forms a tight constricting band behind the glans penis. The glans penis is swollen and congested, while the shaft of the penis appears normal. What is the most suitable initial management?

      Your Answer:

      Correct Answer: Ice packs and manual compression

      Explanation:

      Paraphimosis: Causes, Symptoms, and Treatment Options

      Paraphimosis is a medical condition that occurs when the foreskin of the penis becomes trapped behind the head of the penis, leading to swelling and pain. This condition is considered a medical emergency as it can cause serious complications if left untreated. In this article, we will discuss the causes, symptoms, and treatment options for paraphimosis.

      Causes:
      Paraphimosis can occur due to a variety of reasons, including:

      – Trauma to the penis
      – Infection
      – Poor hygiene
      – Sexual activity
      – Medical procedures, such as catheterization

      Symptoms:
      The symptoms of paraphimosis include:

      – Swelling and pain in the penis
      – Inability to retract the foreskin
      – Discoloration of the penis
      – Difficulty urinating

      Treatment Options:
      The treatment for paraphimosis depends on the severity of the condition. In mild cases, the swelling can be reduced using gentle compression, ice, or osmosis. Topical lidocaine gel may also be used to reduce pain and discomfort.

      In more severe cases, multiple punctures or injections of hyaluronidase may be required. In some cases, a dorsal incision may be necessary to release the trapped foreskin. A general anesthetic may be required for these procedures.

      If a catheter is present, it should be removed temporarily until the paraphimosis has resolved.

      In conclusion, paraphimosis is a serious medical condition that requires prompt treatment to prevent complications. If you experience any symptoms of paraphimosis, seek medical attention immediately.

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      • Kidney And Urology
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  • Question 104 - A 75-year-old man comes to the General Practitioner (GP) because of incontinence. He...

    Incorrect

    • A 75-year-old man comes to the General Practitioner (GP) because of incontinence. He only rarely visits the GP. On examination, his bladder is palpable. During the conversation, he appears to have mild cognitive impairment.
      Which of the following is the most likely cause?

      Your Answer:

      Correct Answer: Benign prostatic hyperplasia

      Explanation:

      Understanding Overflow Incontinence: Causes and Risk Factors

      Overflow incontinence is a condition where the bladder is always full, causing frequent leakage of urine. This is commonly caused by bladder outlet obstruction, such as benign prostatic hyperplasia, prostate cancer, or urethral stricture. However, it can also be caused by lesions affecting sacral segments or peripheral autonomic fibers, resulting in an atonic bladder with loss of sphincter coordination.

      Medications should also be considered as a possible cause of new-onset urinary incontinence, especially in elderly individuals who often take multiple medications. Drugs with anticholinergic effects, α adrenergic agonists, and calcium channel blockers can cause chronic retention, either alone or by exacerbating other causes.

      Severe cognitive impairment can increase the risk of urinary incontinence and worsen other causes. While mild cognitive impairment is unlikely to be the main cause, it should still be considered as a contributing factor.

      Understanding the causes and risk factors of overflow incontinence can help healthcare professionals provide appropriate treatment and management for their patients.

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  • Question 105 - A 45-year-old man presents to the clinic for a new patient medical evaluation....

    Incorrect

    • A 45-year-old man presents to the clinic for a new patient medical evaluation. During his assessment, his urine dipstick test reveals the presence of blood+ and protein+. He reports no lower urinary tract symptoms or history of visible haematuria, and has no significant medical history. His blood pressure measures 140/92 mmHg. Over the course of the next two weeks, he submits two additional urine samples, both of which continue to show blood+ and protein+. A blood test reveals mildly elevated creatinine levels within the normal range and an eGFR of 60 ml/min. What is the most appropriate management approach for this patient?

      Your Answer:

      Correct Answer: Refer to a urologist

      Explanation:

      Microscopic Haematuria and Proteinuria: Clinical Relevance and Referral

      Here we have an incidental finding of microscopic haematuria and proteinuria. Microscopic haematuria is considered clinically relevant if present on at least two out of three samples tested at weekly intervals. A dipstick showing ‘trace’ blood should be considered negative, while blood 1+ or more is significant. Additionally, this patient has persistent proteinuria 1+ in all samples.

      If there had been no proteinuria, a non-urgent referral to a urologist would have been the best approach given the patient’s age. However, with the presence of proteinuria, referral to a renal physician is indicated as per NICE guidance. It is important to consider these findings and take appropriate action to ensure the best possible patient outcomes.

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  • Question 106 - A 25-year-old man presented with bloody discolouration of his urine over the past...

    Incorrect

    • A 25-year-old man presented with bloody discolouration of his urine over the past few days, following a recent respiratory tract infection. Urine testing confirmed haematuria and proteinuria, which had also been noted on two previous occasions after respiratory tract infections. He was referred for renal opinion and a biopsy revealed a focal proliferative glomerulonephritis. What is the most likely underlying diagnosis based on this clinical presentation?

      Your Answer:

      Correct Answer: IgA nephropathy

      Explanation:

      IgA nephropathy is a common type of glomerulonephritis that is characterized by the presence of mesangial IgA deposits. This condition is often triggered by an abnormal immune response to viral or other antigens, resulting in the formation of macromolecular aggregates that accumulate in the glomerular mesangium. IgA nephropathy typically presents with macroscopic hematuria and may be associated with upper respiratory or other infections. It is more common in men and tends to affect children over 10 years of age and young adults. Treatment may involve high-dose prednisolone or immunosuppressive drugs, but some patients may eventually develop end-stage renal failure.

      Goodpasture’s syndrome is an autoimmune disease that can cause diffuse pulmonary hemorrhage, glomerulonephritis, acute kidney injury, and chronic kidney disease. With aggressive treatment, the prognosis has improved, with a one-year survival rate of 70-90%.

      Henoch-Schönlein purpura is a condition that shares similarities with IgA nephropathy and may be a variant of the same disease. About 20% of patients with IgA nephropathy develop impaired renal function, and 5% develop end-stage renal failure.

      Membranous glomerulonephritis is the most common cause of nephrotic syndrome in adults and may present as nephritic syndrome or hypertension. It is characterized by widespread thickening of the glomerular basement membrane and may be idiopathic or due to systemic lupus erythematosus, hepatitis B, malignancy, or the use of certain medications. About 30-50% of patients with membranous glomerulonephritis progress to end-stage kidney disease.

      Minimal change nephropathy is responsible for most cases of nephrotic syndrome in children under 5 years of age and can also occur in adults. It is called minimal change because the only detectable abnormality is fusion and deformity of the foot processes under the electron microscope. Prognosis is generally good for the majority of patients.

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  • Question 107 - Which test is helpful in diagnosing and tracking treatment progress for patients with...