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Phase 2

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Phase 2 Kate McDonald and Rebecca Marlor The Peer Teaching Society is not liable for false or misleading information In children with recurrent UTIs you may wish ... – PowerPoint PPT presentation

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Title: Phase 2


1

Urology
  • Phase 2
  • Kate McDonald and Rebecca Marlor

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or misleading information
2
Aims
  • To understand the diagnosis, investigation and
    management of some common urological conditions

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or misleading information
3
Introduction
  • Benign prostatic obstruction
  • Prostate Cancer
  • Urinary tract infections (UTIs)
  • Acute kidney injury (AKI)
  • Chronic kidney disease (CKD)

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or misleading information
4
Benign Prostatic Hyperplasia
  • Definitions
  • BPH Benign prostatic hyperplasia (histological)
  • BPE Benign prostatic enlargement (DRE)
  • BPO Benign prostatic obstruction

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or misleading information
5
Benign 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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6
Benign 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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7
Benign Prostatic Obstruction
  • Differential Diagnosis
  • Prostate Cancer
  • Urinary bladder Cancer
  • Bladder stone
  • Urethral stricture
  • Prostatitis
  • Detrusor overactivity

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8
Benign 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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9
Benign Prostatic Obstruction
  • Management
  • Conservative
  • Watchful waiting
  • Medical
  • Alpha adrenergic antagonists (Doxazosin/Tamsulosin
    )
  • 5-alpha reductase inhibitors (Finasteride)
  • Surgical
  • TURP/prostatectomy

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10
Acute 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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11
Acute 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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12
Chronic 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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13
Chronic Urinary Retention!!
  • Investigations
  • Monitor UEs and urinary proteins
  • Upper UT imaging
  • Management
  • Intermittent catheterisation
  • ? Surgery

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14
Prostate Cancer
  • Most common male cancer
  • Hormonally driven - dihydrogentestosterone
  • Adenocarcinoma, peripheral, ?multi-focal
  • Localized
  • Locally advanced
  • Metastatic

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15
(No Transcript)
16
Prostate 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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17
Prostate Cancer
  • Investigations
  • PSA
  • TRUS /- biopsy
  • ?MRI/CT scan
  • ? Isototope bone scan
  • Gleason Grading and Clinical Staging

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18
Prostate Cancer
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19
Prostate Cancer
  • Management
  • Localised Prostate Cancer
  • Watch and wait
  • Active follow up
  • Radical prostatectomy
  • Radiotherapy (brachytherapy/external beam)
  • Focal therapy

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20
Prostate 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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21
Prostate Cancer
  • Management
  • Metastatic Prostate Cancer
  • Hormonal therapies
  • Chemotherapy/radiotherapy to improve symptoms and
    disease control
  • Bisphosphonates

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22
AKI
  • Acute Renal Failure
  • Abrupt onset (lt48 hours) kidney impairment
  • Sustained (gt24 hours) reduction in GFR, UO or both

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23
eGFR
  • 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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24
AKI 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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25
AKIN 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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26
AKI Aetiology
RENAL
PRE RENAL
POST RENAL
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27
Classify 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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28
Answers
Pre Renal Renal Post Renal
B D A
C G E
F H
H
I
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29
Pre 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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30
Renal
  • 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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31
Glomerulonephritis
  • 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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32
Post 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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33
Investigation
  • 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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34
AKI 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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35
Case 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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36
Case 1
HYPERKALAEMIA
  • Tented T waves
  • Flattened P waves
  • Prolonged PR
  • Wide QRS
  • Sine wave pattern, asystole

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37
Case 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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38
Case 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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39
Chronic 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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40
CKD 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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41
CKD 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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42
CKD 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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43
Aetiology
  • 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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44
Clinical 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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45
Clinical 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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46
Investigations
  • 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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47
Management
  • Treat reversible causes
  • Obstruction?
  • Avoid Nephrotoxins
  • NSAIDs, Gentamicin, Li, Contrast
  • Treat complications
  • Dialysis/ Transplant

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48
Complications
  • 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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49
Renal 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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50
Assessing 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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51
Lower 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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52
Lower 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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53
Lower Urinary Tract Infection
  • Investigations
  • Urine dip
  • MSU MCS
  • If infection is complicated consider UEs, FBCs
    and blood cultures

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54
Lower 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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55
Acute 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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56
Acute 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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57
Acute 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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58
Acute 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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59
MEQ
  • 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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60
MEQ
  • 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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61
MEQ
  • 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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62
MEQ
  • 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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63
MEQ
  • 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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64
MEQ
  • 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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65
MEQ 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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66
MEQ 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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67
MEQ 2
  • State 3 treatments that may be used in this
    condition (3)
  • Prostate surgery
  • Radiotherapy
  • Anti-androgen therapy
  • Orchiectomy

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68
MEQBonus 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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69
EMQ
  • 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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70
EMQ
  • 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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71
EMQ
  • 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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