Title: Phase 2
1 Urology
- Phase 2
- Kate McDonald and Rebecca Marlor
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2Aims
- To understand the diagnosis, investigation and
management of some common urological conditions
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3Introduction
- Benign prostatic obstruction
- Prostate Cancer
- Urinary tract infections (UTIs)
- Acute kidney injury (AKI)
- Chronic kidney disease (CKD)
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4Benign Prostatic Hyperplasia
- Definitions
- BPH Benign prostatic hyperplasia (histological)
- BPE Benign prostatic enlargement (DRE)
- BPO Benign prostatic obstruction
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5Benign Prostatic Hyperplasia
- Common in elderly men (60-70 years old)
- Usually asymptomatic until late on
- Mechanism poorly understood
- Expansion of the central zone, effects both the
glandular and connective tissue
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6Benign Prostatic Obstruction
Symptoms Signs
Storage symptoms Frequency Smooth enlarged prostate on DRE, Palpable median sulcus
Urgency
Nocturia
Overflow incontinence
Voiding Terminal dribbling
Difficult initiation
Poor flow/straining
Hesitancy
Overflow incontinence
Inadequate emptying of bladder
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7Benign Prostatic Obstruction
- Differential Diagnosis
- Prostate Cancer
- Urinary bladder Cancer
- Bladder stone
- Urethral stricture
- Prostatitis
- Detrusor overactivity
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8Benign Prostatic Obstruction
- Investigations
- ? PSA
- Symptom questionnaire (IPSS)
- Urinalysis
- UEs (Creatinine), FBCs, LFTs
A man presents with LUTS and you think it is
probable he has BPH, what investigations would
you want to arrange?
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9Benign Prostatic Obstruction
- Management
- Conservative
- Watchful waiting
- Medical
- Alpha adrenergic antagonists (Doxazosin/Tamsulosin
) - 5-alpha reductase inhibitors (Finasteride)
- Surgical
- TURP/prostatectomy
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10Acute Urinary Retention!!
67 year old gentleman presents with 24/24
inability to pass urine (anuria) and 12/24
supra-pubic abdominal pain? You suspect he has
acute urinary retention? What are the different
causes?
- Causes
- Benign Prostatic Hyperplasia
- Prostate cancer
- Prostatitis
- Neurological (disc rupture/metastasis)
- Urethral pathology
- Pelvic mass lesions/constipation
- Anticholinergic drugs
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11Acute Urinary Retention!!
- EMERGENCY!
- Check for neurological deficits!!
- Dont measure PSA
- Catheterization
- Urine output
- ? Surgery
Symptoms Signs
SUDDEN Inability to pass urine Bladder palpable and distended
Supra-pubic pain Tender supra-pubicly
Enlarged prostate
Agitation
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12Chronic Urinary Retention!!
- Incomplete bladder emptying
- Often asymptomatic, but can get LUTS overflow
incontinence, NOT painful! - Acute on chronic retention
- Hydronephrosis bladder hypertrophy -gt chronic
renal failure
What serious complications do we worry about?
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13Chronic Urinary Retention!!
- Investigations
- Monitor UEs and urinary proteins
- Upper UT imaging
- Management
- Intermittent catheterisation
- ? Surgery
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14Prostate Cancer
- Most common male cancer
- Hormonally driven - dihydrogentestosterone
- Adenocarcinoma, peripheral, ?multi-focal
- Localized
- Locally advanced
- Metastatic
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15(No Transcript)
16Prostate Cancer
Symptoms
? LUTS
Acute urinary retention
Back/perineal or testicular pain
Haematuria
Stress incontinence
? Constipation, leg swelling
Weight loss
Anorexia
Fatigue
?Bone pain pathological fractures
What would you expect to find on DRE?
DRE Asymmetrical nodular enlargement of the
prostate Hard and Craggy Loss of median sulcus
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17Prostate Cancer
- Investigations
- PSA
- TRUS /- biopsy
- ?MRI/CT scan
- ? Isototope bone scan
- Gleason Grading and Clinical Staging
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18Prostate Cancer
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19Prostate Cancer
- Management
- Localised Prostate Cancer
- Watch and wait
- Active follow up
- Radical prostatectomy
- Radiotherapy (brachytherapy/external beam)
- Focal therapy
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20Prostate Cancer
- Management
- Locally advanced Prostate Cancer
- Neoadjuvent hormonal therapy
- LHRH Agonists (Goserelin injections) hot
flushes, lethargy, loss of sexual function - Anti-Androgens gynaecomastia, nipple tenderness,
sometimes retain sexual function - Radiotherapy
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21Prostate Cancer
- Management
- Metastatic Prostate Cancer
- Hormonal therapies
- Chemotherapy/radiotherapy to improve symptoms and
disease control - Bisphosphonates
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22AKI
- Acute Renal Failure
- Abrupt onset (lt48 hours) kidney impairment
- Sustained (gt24 hours) reduction in GFR, UO or both
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23eGFR
- Estimated Glomerular Filtration Rate
- Based on serum creatinine, age, sex and race
- Calculated using complicated mathematical
equationModification of Diet in Renal Disease
(MDRD) - Normal lt 100 ml/min/1.73m2
- Independent risk factor for CVS disease
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24AKI Classification
- NICE Kidney Disease Improving Global
Outcome score (KDIGO) - Officially (any of)
- Rise in serum creatinine gt 26µmol/L in 48 hours
- gt50 rise in serum creatinine within 7 days
- Fall in UO (lt0.5ml/kg/hr) for gt6 hours (adults)
or gt8 hours (paeds) - gt25 fall in eGFR in children and young people
within 7 days
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25AKIN Classification
Stage Serum Creatinine UO criteria
1 Increase gt 26µmol/L within 48 hours or increase gt 1.5-1.9X reference creatinine lt0.5mL/kg/hr for gt6 hours
2 Increase gt 2 -2.9 X reference creatinine lt0.5mL/kg/hr for gt12 hrs
3 Increase gt 3X reference creatinine, increase gt4mg/dl or started renal replacement therapy lt0.3mL/kg/hr gt24 hrs or anuria for 12hrs
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26AKI Aetiology
RENAL
PRE RENAL
POST RENAL
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27Classify the following causes..
- A Catheter blocked
- B Congestive Heart Failure
- C Haemorrhage
- D Goodpastures
- E Renal calculi
- F ACE inhibitor
- G Acute Tubular Necrosis
- H NSAIDs
- I Renal Artery Stenosis
- J BPH
PRE RENAL, RENAL or POST RENAL???
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28Answers
Pre Renal Renal Post Renal
B D A
C G E
F H
H
I
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29Pre renal
- COMMONEST CAUSE OF AKI
- Decreased intravascular volume
- Haemorrhage, shock, burns, DV
- Decreased effective circ volume
- CCF, cirrhosis
- Drugs
- ACE, ARB, NSAIDs
- Renal artery stenosis
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30Renal
- Acute Tubular necrosis (ATN)
- Secondary to hypoperfusion/toxin
- Red cells/granular casts
- Tubular interstitial nephritis (antibiotics,
NSAIDS) - Acute and chronic pyelonephritis
- Glomerulonephritis
- Hepatorenal syndrome
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31Glomerulonephritis
- IgA nephropathy
- Young male with recurrent haematuria after URTI
- Goodpastures
- Anti-glomerular basement membrane disease
- Haemoptysis and haematuria
- Proliferative GN
- Post strep infection
- Minimal change
- Common in paeds
- Rapidly progressive GN
- ESRF in days
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32Post renal
- Intraluminal
- Calculus, clot, sloughed papilla
- Intramural
- Ureteric malignancy, stricture, post raditaion
fibrosis, bladder ca, BPH - Extrinsic
- Retroperitoneal fibrosis, pelvic malignancy.
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33Investigation
- Urine
- Dipstick leuks, nitrites, blood, prot, glucose
- Albumincreatinine to quantify
- ?osmolality, ?culture
- Bloods
- FBC, UE, LFT, clotting, ESR/CRP
- ?blood culture, ?ABG, ?Immunology
- ECG
- Imaging
- US 1st line
- CT
- ?Renal Biopsy
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34AKI Management
- TREAT CAUSE
- Assess fluid status..is the patient dehydrated?
- Low UO, JVP, poor tissue turgor, low BP, high
pulse - ? IV FLUIDS
- Identify and relieve any obstruction.
- Stop nephrotoxic drugs!
- Dialysis if renal function does not recover
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35Case 1
- 68 year old male gen unwell fatigue, malaise,
NV, anorexia - Started on ramipril for HTN
- PMH IHD
- O/E Bilateral Renal Bruits
- Differentials? What investigations?
- Bloods- High urea and creatinine ? AKI
- Urine NAD
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36Case 1
HYPERKALAEMIA
- Tented T waves
- Flattened P waves
- Prolonged PR
- Wide QRS
- Sine wave pattern, asystole
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37Case 1
- IV Calcium (cardioprotective)
- 10 ml of 10 Ca gluconate IV
- IV Insulin glucose (increases intracellular
uptake) - Salbutamol nebuliser
- Patient potassium stabilises
- What next?
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38Case 1
- Stop ramipril
- Find and treat cause
- CT bilateral renal stenosis, atheromatous
changes - Refer to vascular stents which improves BP
control
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39Chronic Renal Failure
- Kidney damage 3/12 based on findings of
abnormal kidney structure or function - OR
- GFRlt60mL/min/1.73m2 for gt3/12 with or without
evidence of kidney damage.
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40CKD Classification
Stage GFR (mL/min/1.73m2) Notes
1 gt90 Normal GFR evidence of renal damage
2 60-89 Slight decrease in GFR evidence of renal damage
3A 45-59 Moderate decrease in GFR evidence of renal damage
3B 30-44 Moderate decrease in GFR evidence of renal damage
4 15-29 Severe decrease in GFR evidence of renal damage
5 lt15 Established renal failure
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41CKD Classification
- Evidence of Renal Damage
- Persistent microalbuminuria
- Persistent proteinuria
- Persistent haematuria
- Structural Abnormalities of the kidneys by USS eg
ADPKD - Positive biopsy for chronic glomerulonephritis
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42CKD Classification
- Limitations
- Validated for patients with established RF
- Most elderly people are in Stage 3 by eGFR
- eGFR very dependent on diet
- Formula less accurate for higher eGFR
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43Aetiology
- Vascular HTN, Renovascular disease
- Infective/Inflamm GN
- Trauma
- AI SLE, PAN
- Metabolic DM
- Iatrogenic/Idiopathic Drugs, contrast
- Neoplastic Myeloma, Renal Ca, Prostate Ca
- Congenital ADPKD, Fabrys, Alports
-
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44Clinical Presentation
- Symptoms
- N/V, anorexia
- Peripheral neurpathy High urea
- Pruritus
- Lethary
- Confusion
- Sx of underlying cause
- Urinary sx dysuria, increased frequency,
nocturia, terminal dribbling - SLE rash, arthalgia, dry mouth, pleuritic chest
pain
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45Clinical Presentation
- Hx
- PMH
- DM,IHD.
- DH
- NSAIDs
- FH
- ADPKD
-
- O/E
- HTN
- Palpable kidneys
- Palpable bladder
- PR- enlarged prostate
- Renal or femoral bruits
- Rash
- Peripheral Oedema
- Pallor
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46Investigations
- Blood
- FBC, UE, LFT, Lupus/vasculitis/myeloma screen
- Urine
- MCS, dipstick, ACR
- Imaging
- USS
- CXR, ECG
- Renal biopsy if cause unclear
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47Management
- Treat reversible causes
- Obstruction?
- Avoid Nephrotoxins
- NSAIDs, Gentamicin, Li, Contrast
- Treat complications
- Dialysis/ Transplant
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48Complications
- Fl uid overload
- A cidosis
- S x of uraemia (fatigue, anorexia, pruritus)
- H TN
- B one disease
- A naemia
- C VS disease
- K Hyperkalaemia
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49Renal Osteodystrophy
- Manifestation of renal disease
- Pathophysiology
- Decreased activation of 1.25 vit D.
- Lower Ca abs from gut
- Increased PTH ? 2O hyperPTH
- Increased bone turnover
- Rugger jersey spine
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50Assessing renal function..
- THINK is this ACUTE or CHRONIC?
- Hx Cormordity chronic
- Longstanding decrease in eGFR
- SIZE OF KIDNEYS usually small in chronic (lt9cm)
- Absence of anaemia, low calcium suggests acute
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51Lower Urinary Tract Infection
- Urethritis Cystitis symptoms of UTI
- Pathophysiology
- alkaline urine
- ?urine osmolarity
- ?micturation volume,
- ? commensals
- - Majority Contamination with bowl flora (E-Coli)
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52Lower Urinary Tract Infection
Symptoms Signs
Frequency Haematuria (Microscopic/Macroscopic)
Dysuria Cloudy smelly urine
Suprapubic pain during and after voiding
Strangury
Features suggestive of pyelonephritis fever,
rigors, loin pain, NV, guarding and tenderness
- Differential Diagnosis
- Urethritis (Chlamydia)
- Urethral syndrome
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53Lower Urinary Tract Infection
- Investigations
- Urine dip
- MSU MCS
- If infection is complicated consider UEs, FBCs
and blood cultures
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54Lower Urinary Tract Infection
- Management
- Increase fluid intake (gt2Litres/day)
- Trimethoprim 200mg PO BD (3/7)
- Alternative Nitrofurantoin (in pregnancy) (PO)
- Ciprofloxacin and co-amoxiclav (PO)
First line antibiotic for LUTI? What about in
pregnancy?
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55Acute Pyelonephritis
- Loin pain, fever and tender renal angle
- Nausea, vomitting, (Septic shock)
- Usually an ascending infection
- Complications perinephric abscesses, papillary
necrosis, ureteric obstruction, AKI,
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56Acute Pyelonephritis
- Differential Diagnosis (Pyelonephritis)
- Acute appendicitis
- Diverticulitis
- Cholecystitis
- Ruptured ovarian cyst
- Ectopic pregnancy
Differential diagnosis of acute
pyelonephritis?
ALWAYS consider in pre-menopausal women!!
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57Acute Pyelonephritis
- Investigations
- Dipstick
- MSU MCS
- Renal tract USS/CT
- Pelvic examination (women)DRE (men)
- Blood cultures (if pyrexial)
Investigations for patient with
pyelonephritis?
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58Acute Pyelonephritis
- Management
- ? Hospital admission
- Co-amoxiclav/Ciprofloxacin (PO)
- OR Gentamycin Cefuroxime (IV)
- Paracetamol
- Maintain high fluid intake
First line oral antibiotic treatment? IV
antibiotic treatment regime?
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59MEQ
- An 80 year-old man attends his General
Practitioner complaining of passing urine very
frequently. His symptoms started about 5 years
ago and have gradually worsened, so that for the
last 12 months he has been passing urine hourly
but never felt like his bladder was properly
empty. During the last 2 days, he noticed some
blood in his urine and felt hot and sweaty. This
prompted him to seek medical advice. His GP
diagnoses a lower urinary tract infection. - 1. From the patients history, what condition
may have predisposed to the development of this
infection? (2 marks)
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60MEQ
- An 80 year-old man attends his General
Practitioner complaining of passing urine very
frequently. His symptoms started about 5 years
ago and have gradually worsened, so that for the
last 12 months he has been passing urine hourly
but never felt like his bladder was properly
empty. During the last 2 days, he noticed some
blood in his urine and felt hot and sweaty. This
prompted him to seek medical advice. His GP
diagnoses a lower urinary tract infection. - CHRONIC URINARY RETENTION
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61MEQ
- 2. List 4 other symptoms you might enquire about
in relation to the patients chronic urinary
problems (2 marks) - LUTS Nocturia
- Hesistancy
- Terminal dribbling Poor urinary
stream - Intermittent stream
- Urgency
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62MEQ
- 3. List 2 physical signs that you may expect to
elicit on abdominal/PR exam (2 marks) - Palpable bladder
- Enlarged prostate
- Palpable kidney
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63MEQ
- 4. The patient is referred to a urologist for
definitive treatment. In the meantime, a
midstream specimen of urine is sent for culture.
The results of a gram stain show a gram negative
bacillus. List 2 possible pathogens that may be
responsible for the patients infection. (2
marks 1 mark per response) - Escherichia coli (E. coli)
- Enterobacter
- Klebsiella sp.
- Pseudomonas aeruginosa
- Serratia sp.
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64MEQ
- 5. The urologist recommends that the patient
undergo an operation to relieve his chronic
urinary symptoms. What operation is he most
likely to have suggested? (2 marks) - TURP (Transurethral resection of prostate)
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65MEQ 2
- A 61-year-old man presents to his General
Practitioner complaining of increasing difficulty
in passing urine. On rectal examination the GP
feels an enlarged hard, irregular prostate gland
and suspects the diagnosis of carcinoma of the
prostate. The patient is referred to the Urology
department at the local hospital. - State two tests that will aid confirmation of
the diagnosis (2) - Transrectal USS
- Prostatic biopsy
- Prostate Specific Antigen
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66MEQ 2
- The results of these tests confirm prostate
cancer. - Give two investigations, which will assist in
assessing the extent of the disease (2) - Transrectal USS
- CT scan of abdomen (and chest)
- Alk phosphatase
- Serum Calcium
- Isotope bone scan
- Plain radiographs of axial skeleton
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67MEQ 2
- State 3 treatments that may be used in this
condition (3) - Prostate surgery
- Radiotherapy
- Anti-androgen therapy
- Orchiectomy
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68MEQBonus question!
- Treatment is conducted and the GP manages his
subsequent follow up care. Three months later
the patient becomes increasingly unwell. He
complains increased thirst and has also noticed
increased urinary frequency. He has become
markedly constipated and his wife says that he is
has become far less mentally sharp than he had
been previously. The GP arranges admission to
hospital. - What is the most likely cause of these new
symptoms? (1) - HYPERCALCAEMIA (?bony mets)
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69EMQ
- a. Amoxicillin f. Flucoxacillin
- b. Antibiotic treatment is not indicated g. Gentam
icin - c. Ceftazidime h. Nitrofurantoin
- d. Cephalexin i. Trimethoprim
- e. Ciprofloxacin j. Vancomycin
- A 23-year-old woman presents to her GP with a
2-day history of urinary frequency and dysuria.
Her last menstrual period was six weeks
previously. She reports that she experienced
facial swelling and wheezing when she was given
either penicillins or cephalosporins as a
teenager. Microscopy of her urine shows numerous
white and red blood cells. Culture yields gt105
/ml of a fully sensitive Escherichia coli. - H
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70EMQ
- a. Amoxicillin f. Flucoxacillin
- b. Antibiotic treatment is not indicated g. Gentam
icin - c. Ceftazidime h. Nitrofurantoin
- d. Cephalexin i. Trimethoprim
- e. Ciprofloxacin j. Vancomycin
- A 60-year-old man is admitted with a fever. He
has had repeated hospital admissions over the
preceding year for an unrelated condition, and is
known to carry MRSA in his nose. On taking a
history, he describes recent onset urinary
frequency, nocturia and loin pain. An MSU is
sent to the laboratory. Microscopy shows
numerous white blood cells and a culture yields
gt105 /ml of Staphylococcus aureus. This morning
he has become hypotensive and confused. - J
-
-
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71EMQ
- a. Amoxicillin f. Flucoxacillin
- b. Antibiotic treatment is not indicated g. Gentam
icin - c. Ceftazidime h. Nitrofurantoin
- d. Cephalexin i. Trimethoprim
- e. Ciprofloxacin j. Vancomycin
- On admission to a residential home, a urine
sample is sent from a 75-year-old man with a
long-standing indwelling urinary catheter,
because it looks cloudy and contains protein on
dipstick. The patient is otherwise well. The
culture yields gt105 /ml of a Pseudomonas
aeruginosa sensitive to standard antipseudomonal
antibiotics. - B
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