UKMLA Prep > Renal 2 🫘 > Flashcards

Renal 2 🫘 Flashcards

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1
Q

What is the terminology change for microscopic or dipstick positive haematuria?

A

Non-visible haematuria

Previously known as microscopic or dipstick positive haematuria, now termed non-visible haematuria.

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2
Q

What is visible haematuria?

A

Macroscopic haematuria

Visible haematuria is the term now used for what was previously known as macroscopic haematuria.

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3
Q

What percentage of the population is affected by non-visible haematuria?

A

Approximately 2.5%

Non-visible haematuria is found in around 2.5% of the population.

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4
Q

List four causes of transient or spurious non-visible haematuria.

A
  • Urinary tract infection
  • Menstruation
  • Vigorous exercise
  • Sexual intercourse

Transient or spurious non-visible haematuria usually settles after about 3 days.

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5
Q

What are the causes of persistent non-visible haematuria?

A
  • Cancer (bladder, renal, prostate)
  • Stones
  • Benign prostatic hyperplasia
  • Prostatitis
  • Urethritis (e.g., Chlamydia)
  • Renal causes (IgA nephropathy, thin basement membrane disease)

Persistent non-visible haematuria requires further investigation.

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6
Q

What foods can cause spurious red/orange urine?

A
  • Beetroot
  • Rhubarb

These foods can lead to a false positive for blood in urine.

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7
Q

What is the test of choice for detecting haematuria?

A

Urine dipstick

Urine dipstick is the preferred method for detecting haematuria.

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8
Q

Define persistent non-visible haematuria.

A

Blood present in 2 out of 3 samples tested 2-3 weeks apart

This definition helps in identifying cases that require further investigation.

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9
Q

What are the NICE urgent cancer referral guidelines for patients aged 45 years or older?

A
  • Unexplained visible haematuria without urinary tract infection
  • Visible haematuria that persists or recurs after successful treatment of urinary tract infection

These guidelines were updated in 2015.

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10
Q

What is nephrotic syndrome characterized by?

A
  • Proteinuria (> 3g/24hr)
  • Hypoalbuminaemia (< 30g/L)
  • Oedema

Nephrotic syndrome can arise from various glomerular diseases.

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11
Q

What are common primary causes of nephrotic syndrome?

A
  • Minimal change disease
  • Focal segmental glomerulosclerosis (FSGS)
  • Membranous nephropathy

These are key primary causes of nephrotic syndrome.

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12
Q

List the secondary causes of nephrotic syndrome.

A
  • Diabetes mellitus
  • Systemic lupus erythematosus (SLE)
  • Amyloidosis
  • Infections (HIV, hepatitis B and C)
  • Drugs (NSAIDs, gold therapy)

Secondary causes often relate to systemic diseases.

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13
Q

What is the pathophysiological mechanism of nephrotic syndrome?

A

Damage to the glomerular basement membrane and podocytes leading to increased permeability to proteins

This mechanism results in proteinuria, hypoalbuminaemia, and subsequent oedema.

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14
Q

What initial investigations are done for nephrotic syndrome?

A
  • Urine dipstick for proteinuria
  • MSU to exclude urinary tract infection
  • Early morning urinary protein:creatinine ratio or albumin:creatinine ratio
  • FBC and coagulation screen
  • Urea and electrolytes

These investigations help in confirming the diagnosis.

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15
Q

What is the frequency of calcium oxalate stones?

A

40%

Calcium oxalate stones are the most common type of renal stone.

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16
Q

What are the clinical features of a urinary tract infection?

A
  • Dysuria
  • Urinary frequency
  • Urinary urgency
  • Cloudy/offensive smelling urine
  • Lower abdominal pain
  • Fever (typically low-grade)
  • Malaise

Symptoms can vary in severity and presentation.

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17
Q

What is the role of urine dipstick in diagnosing UTI in women under 65 years?

A

Aid diagnosis

Urine dipsticks can help confirm UTI likelihood but should not be used in women over 65 years, men, or catheterised patients.

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18
Q

What is acute interstitial nephritis primarily caused by?

A

Drugs (most common cause), particularly antibiotics

Common drugs include penicillin, rifampicin, NSAIDs, allopurinol, and furosemide.

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19
Q

List symptoms associated with tubulointerstitial nephritis with uveitis (TINU).

A
  • Fever
  • Weight loss
  • Painful, red eyes

TINU typically occurs in young females.

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20
Q

What are the three traditional classifications of acute kidney injury (AKI) causes?

A
  • Prerenal
  • Intrinsic
  • Postrenal

These classifications help in identifying the underlying issues causing AKI.

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21
Q

What is a common prerenal cause of AKI?

A

Hypovolaemia secondary to diarrhoea/vomiting

Prerenal causes are often due to reduced blood flow to the kidneys.

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22
Q

What is a common intrinsic cause of AKI?

A

Acute tubular necrosis (ATN)

Intrinsic causes involve direct damage to the kidney tissue.

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23
Q

What is a postrenal cause of AKI?

A

Kidney stone in ureter or bladder

Postrenal causes relate to obstructions affecting urine flow from the kidneys.

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24
Q

What are the risk factors for AKI?

A
  • Chronic kidney disease
  • Other organ failure/chronic disease
  • History of acute kidney injury
  • Use of nephrotoxic drugs
  • Age 65 years or over
  • Oliguria
  • Neurological or cognitive impairment

Identifying these risk factors can help in prevention strategies.

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25
What happens when kidneys stop working?
* Reduced urine output (oliguria) * Fluid overload * Rise in molecules like potassium, urea, and creatinine ## Footnote These changes indicate renal dysfunction and the need for intervention.
26
What are common symptoms of progressing AKI?
* Reduced urine output * Pulmonary and peripheral oedema * Arrhythmias * Features of uraemia (e.g., pericarditis, encephalopathy) ## Footnote Symptoms can vary based on the severity of renal failure.
27
What is the recommended method to detect AKI?
Urea and electrolytes (U&Es) blood test ## Footnote This test provides key markers for renal function.
28
What criteria can be used to diagnose AKI according to NICE?
* Rise in serum creatinine of 26 micromol/litre within 48 hours * 50% or greater rise in serum creatinine within the past 7 days * Fall in urine output to less than 0.5 ml/kg/hour for more than 6 hours ## Footnote These criteria help in defining acute kidney injury.
29
What is the management approach for AKI?
Supportive care and careful fluid balance ## Footnote Management focuses on ensuring kidney perfusion while avoiding fluid overload.
30
What is the role of renal replacement therapy in AKI?
Used when medical treatment fails for complications like hyperkalaemia, pulmonary oedema, acidosis, or uraemia ## Footnote Haemodialysis is a common form of renal replacement therapy.
31
What is the urine sodium level in pre-renal uraemia?
< 20 mmol/L ## Footnote This indicates that kidneys are attempting to conserve sodium.
32
What is the urine sodium level in acute tubular necrosis?
> 40 mmol/L ## Footnote In ATN, kidneys lose the ability to conserve sodium.
33
What is a fluid challenge in relation to kidney function?
Good or Poor response based on fluid retention ## Footnote A good response indicates the kidneys are functioning properly, while a poor response suggests potential kidney issues.
34
What fractional urea excretion percentage indicates poor kidney function?
>35% ## Footnote A fractional urea excretion above 35% suggests renal impairment.
35
What urine:plasma osmolality ratio indicates poor kidney function?
< 1.1 ## Footnote A low urine:plasma osmolality indicates a dilutional state, often seen in renal failure.
36
What specific gravity value indicates poor kidney function?
< 1010 ## Footnote A specific gravity below 1010 suggests dilute urine, often linked to renal impairment.
37
What are the features of AKI? (4)
* Raised urea * Raised creatinine * Raised potassium * Muddy brown casts in urine ## Footnote These features help in diagnosing acute kidney injury.
38
What are the diagnostic criteria for AKI?
* Rise in creatinine of 26µmol/L or more in 48 hours * >= 50% rise in creatinine over 7 days * Fall in urine output to < 0.5ml/kg/hour for over 6 hours in adults * >= 25% fall in eGFR in children/young adults in 7 days ## Footnote These criteria are essential for the diagnosis of AKI.
39
What are the KDIGO staging criteria for AKI Stage 1?
* Increase in creatinine to 1.5-1.9 times baseline * Increase in creatinine by ≥26.5 µmol/L * Reduction in urine output to <0.5 mL/kg/hour for ≥ 6 hours ## Footnote Stage 1 indicates a mild degree of AKI.
40
What are the referral criteria for a nephrologist? (7)
* Renal transplant * ITU patient with unknown cause of AKI * Vasculitis/glomerulonephritis/tubulointerstitial nephritis/myeloma * AKI with no known cause * Inadequate response to treatment * Complications of AKI * Stage 3 AKI ## Footnote These criteria help determine when to refer for specialized care.
41
What are the two main causes of acute tubular necrosis (ATN)?
* Ischaemia * Nephrotoxins ## Footnote Ischaemia may result from shock or sepsis, while nephrotoxins can include drugs like aminoglycosides.
42
What is the most common cause of acute kidney injury (AKI)?
Acute tubular necrosis (ATN) ## Footnote ATN is frequently seen in clinical practice as a cause for AKI.
43
What are the features of rhabdomyolysis? (7)
* Acute kidney injury with disproportionately raised creatinine * Elevated creatine kinase (CK) * Myoglobinuria * Hypocalcaemia * Elevated phosphate * Hyperkalaemia * Metabolic acidosis ## Footnote These features are critical for diagnosis and management.
44
What management is recommended for rhabdomyolysis?
IV fluids to maintain good urine output ## Footnote This is essential to prevent further kidney damage.
45
What are the risk factors for benign prostatic hyperplasia (BPH)?
* Age * Ethnicity * Family history ## Footnote Age is the primary risk factor, with prevalence increasing significantly in older men.
46
What are the voiding symptoms associated with BPH?
* Weak or intermittent urinary flow * Straining * Hesitancy * Terminal dribbling * Incomplete emptying ## Footnote These obstructive symptoms are common in BPH.
47
What is the International Prostate Symptom Score (IPSS) used for?
Classifying the severity of lower urinary tract symptoms (LUTS) ## Footnote It assesses the impact of LUTS on quality of life.
48
What is the first-line treatment for moderate-to-severe voiding symptoms in BPH?
Alpha-1 antagonists (e.g., tamsulosin) ## Footnote These medications improve symptoms in about 70% of men.
49
What characterizes urinary incontinence (UI)?
Involuntary leakage of urine ## Footnote UI is a common issue, particularly in older females.
50
What initial investigation is recommended for urinary incontinence?
Bladder diaries for a minimum of 3 days ## Footnote This helps track patterns and inform treatment.
51
What is the mnemonic CRABBI used for in multiple myeloma?
* Calcium * Renal * Anaemia * Bleeding * Bone ## Footnote This mnemonic helps remember key features of multiple myeloma.
52
What is nephrotic syndrome characterized by?
* Proteinuria (> 3g/24hr) * Hypoalbuminaemia (< 30g/L) * Oedema ## Footnote This triad is crucial for diagnosing nephrotic syndrome.
53
What are the primary causes of nephrotic syndrome?
* Minimal change disease * Focal segmental glomerulosclerosis * Membranous nephropathy ## Footnote These are common primary causes of nephrotic syndrome.
54
What is the first-line diagnostic tool for testicular cancer?
Ultrasound ## Footnote Ultrasound is essential for evaluating suspected testicular masses.
55
What are the common types of germ-cell tumours?
* Seminomas * Non-seminomas (embryonal, yolk sac, teratoma, choriocarcinoma) ## Footnote Germ-cell tumours account for 95% of testicular cancer cases.
56
What are common symptoms of elevated PTH-rP levels in multiple myeloma?
Constipation, nausea, anorexia, confusion
57
What causes renal damage in multiple myeloma?
Monoclonal production of immunoglobulins leads to light chain deposition within the renal tubules
58
What are other causes of renal impairment in myeloma?
* Amyloidosis * Nephrocalcinosis * Nephrolithiasis
59
How does bone marrow crowding affect erythropoiesis?
It suppresses erythropoiesis, leading to anaemia
60
What condition results from bone marrow crowding and increases the risk of bleeding?
Thrombocytopenia
61
What causes lytic bone lesions in multiple myeloma?
Bone marrow infiltration by plasma cells and cytokine-mediated osteoclast overactivity
62
What is a significant risk associated with the lytic bone lesions in multiple myeloma?
Pathological fractures
63
What leads to increased susceptibility to infection in multiple myeloma patients?
Reduction in the production of normal immunoglobulins
64
What are some other features associated with multiple myeloma? (4)
* Amyloidosis (e.g. macroglossia) * Carpal tunnel syndrome * Neuropathy * Hyperviscosity
65
What does a full blood count typically show in multiple myeloma?
Anaemia
66
What is indicated by rouleaux formation in a peripheral blood film?
Multiple myeloma
67
What is the significance of elevated levels of M protein in the diagnosis of multiple myeloma?
It indicates monoclonal gammopathy
68
What is the purpose of a bone marrow aspiration in multiple myeloma?
To confirm the diagnosis if the number of plasma cells is significantly raised
69
What imaging technique is increasingly recommended for detecting bone lesions in multiple myeloma?
Whole-body MRI
70
What major diagnostic criteria are used for multiple myeloma?
* Plasmacytoma * 30% plasma cells in a bone marrow sample * Elevated levels of M protein
71
What are the minor diagnostic criteria for multiple myeloma? (4)
* 10% to 30% plasma cells in a bone marrow sample * Minor elevations in the level of M protein * Osteolytic lesions * Low levels of antibodies in the blood
72
What is the primary goal of managing multiple myeloma?
To control symptoms, reduce complications, and prolong survival
73
What is 'induction therapy' in the context of multiple myeloma treatment?
A combination of drugs used to treat myeloma
74
What type of transplantation is commonly used in multiple myeloma treatment?
Autologous hematopoietic cell transplantation
75
What is the role of zoledronic acid in multiple myeloma management?
To prevent and manage osteoporosis and fragility fractures
76
What is the most common cause of epididymo-orchitis in sexually active younger adults?
Chlamydia trachomatis and Neisseria gonorrhoeae
77
What are the clinical features of epididymo-orchitis?
* Unilateral testicular pain * Swelling * Urethral discharge (may be present)
78
What is the most important differential diagnosis to exclude in cases of epididymo-orchitis?
Testicular torsion
79
What is the recommended management for epididymo-orchitis caused by an STI?
Urgent referral to a local specialist sexual health clinic
80
What is the standard maintenance fluid requirement for an 80kg patient?
2 litres of water, 80mmol potassium
81
What is a hyperosmolar hyperglycaemic state (HHS)?
A medical emergency characterized by severe hyperglycaemia and dehydration
82
What are the typical clinical features of HHS?
* Polyuria * Polydipsia * Lethargy * Nausea and vomiting * Altered level of consciousness
83
What is the recommended initial management for HHS?
Fluid replacement with IV 0.9% sodium chloride solution
84
What are the major risk factors for erectile dysfunction?
* Cardiovascular disease * Obesity * Diabetes mellitus * Smoking * Alcohol use
85
What is the first-line treatment for erectile dysfunction?
PDE-5 inhibitors (e.g., sildenafil)
86
What are common side effects of PDE-5 inhibitors?
* Visual disturbances * Headache * Flushing * Gastrointestinal side effects
87
What does the presence of blue discolouration of vision indicate?
Use of sildenafil (Viagra)
88
What is the most common inherited cause of kidney disease?
Autosomal dominant polycystic kidney disease (ADPKD) ## Footnote Affects 1 in 1,000 Caucasians.
89
What are the two disease loci identified in ADPKD?
PKD1 and PKD2 ## Footnote Code for polycystin-1 and polycystin-2 respectively.
90
What percentage of ADPKD cases are type 1?
85% of cases.
91
What chromosome is associated with ADPKD type 1?
Chromosome 16.
92
What is the screening investigation for relatives of ADPKD patients?
Abdominal ultrasound.
93
Fill in the blank: Ultrasound diagnostic criteria for patients aged < 30 years with positive family history of ADPKD is _______.
two cysts, unilateral or bilateral.
94
What treatment option is available for select patients with ADPKD?
Tolvaptan (vasopressin receptor 2 antagonist).
95
What are the criteria for using tolvaptan in ADPKD treatment?
* Chronic kidney disease stage 2 or 3 at the start of treatment * Evidence of rapidly progressing disease * Company provides it with the discount agreed in the patient access scheme.
96
What is the most significant factor causing anaemia in chronic kidney disease (CKD)?
Reduced erythropoietin levels.
97
At what GFR level does anaemia usually become apparent in CKD?
Less than 35 ml/min.
98
What is the target haemoglobin level suggested by NICE guidelines for CKD management?
10 - 12 g/dl.
99
What is the common cause of anaemia in renal failure?
Reduced erythropoietin levels, reduced absorption of iron, reduced erythropoiesis, and stress ulceration.
100
What are the basic problems in chronic kidney disease?
* Low vitamin D * High phosphate * Low calcium * Secondary hyperparathyroidism.
101
What is the most commonly used formula to estimate glomerular filtration rate (eGFR)?
Modification of Diet in Renal Disease (MDRD) equation.
102
What variables are used in the MDRD equation?
* Serum creatinine * Age * Gender * Ethnicity.
103
What are the stages of chronic kidney disease based on GFR?
* Stage 1: > 90 ml/min * Stage 2: 60-90 ml/min * Stage 3a: 45-59 ml/min * Stage 3b: 30-44 ml/min * Stage 4: 15-29 ml/min * Stage 5: < 15 ml/min.
104
Name three common causes of chronic kidney disease.
* Diabetic nephropathy * Chronic glomerulonephritis * Hypertension.
105
What is osteitis fibrosa cystica?
Also known as hyperparathyroid bone disease.
106
What are the possible features of chronic kidney disease?
* Oedema * Polyuria * Lethargy * Pruritus * Anorexia * Insomnia * Nausea and vomiting * Hypertension.
107
True or False: ACE inhibitors are first-line treatment for hypertension in CKD.
True.
108
What is the function of furosemide in CKD?
Useful as an anti-hypertensive, particularly when GFR falls below 45 ml/min.
109
What dietary management is suggested for high phosphate levels in CKD?
Reduced dietary intake of phosphate.
110
How should phosphate binders be managed?
* Calcium-based binders * Sevelamer (non-calcium based binder).
111
What is the preferred method for quantifying proteinuria in CKD?
Albumin:creatinine ratio (ACR).
112
What does a confirmed ACR of 3 mg/mmol or more indicate?
Clinically important proteinuria.
113
What is the management for proteinuria in CKD?
* ACE inhibitors or ARBs * SGLT-2 inhibitors.
114
What is minimal change disease often associated with?
Nephrotic syndrome.
115
What is the primary treatment for minimal change disease?
Oral corticosteroids.
116
What defines nocturnal enuresis?
Involuntary discharge of urine at night in a child aged 5 years or older.
117
What is the first-line management for enuresis?
Enuresis alarm.
118
Name a common cause of polyuria.
* Diabetes mellitus * Diuretics * Caffeine and alcohol.
119
What does diabetes insipidus (DI) refer to?
A condition characterized by excessive urination due to inadequate vasopressin.
120
What are the common causes of polyuria?
Diuretics, caffeine & alcohol, diabetes mellitus, lithium, heart failure ## Footnote Common causes occur in more than 1 in 10 patients.
121
What are the infrequent causes of polyuria?
Hypercalcaemia, hyperthyroidism ## Footnote Infrequent causes occur in 1 in 100 patients.
122
What are the rare causes of polyuria?
Chronic renal failure, primary polydipsia, hypokalaemia ## Footnote Rare causes occur in 1 in 1000 patients.
123
What is the very rare cause of polyuria?
Diabetes insipidus ## Footnote Very rare causes occur in less than 1 in 10,000 patients.
124
What is diabetes insipidus (DI)?
A condition characterized by decreased secretion of antidiuretic hormone (ADH) or insensitivity to ADH ## Footnote Cranial DI and nephrogenic DI are the two main types.
125
What are the causes of cranial diabetes insipidus?
Idiopathic, post head injury, pituitary surgery, craniopharyngiomas, infiltrative diseases (histiocytosis X, sarcoidosis), DIDMOAD syndrome, haemochromatosis ## Footnote DIDMOAD is an association of cranial DI, diabetes mellitus, optic atrophy, and deafness.
126
What are the causes of nephrogenic diabetes insipidus?
Genetic mutations, hypercalcaemia, hypokalaemia, lithium, demeclocycline, tubulo-interstitial disease ## Footnote The more common form affects the vasopressin receptor.
127
What are the main features of diabetes insipidus?
Polyuria, polydipsia ## Footnote These symptoms are due to the lack of water reabsorption.
128
How is diabetes insipidus investigated?
High plasma osmolality, low urine osmolality, water deprivation test ## Footnote A urine osmolality of >700 mOsm/kg excludes diabetes insipidus.
129
What is the management for nephrogenic diabetes insipidus?
Thiazides, low salt/protein diet ## Footnote Central diabetes insipidus can be treated with desmopressin.
130
What is the most common urological cancer?
Bladder cancer ## Footnote It most commonly affects males aged between 50 and 80 years.
131
What increases the risk of bladder cancer?
Smoking, exposure to hydrocarbons, chronic bladder inflammation from Schistosomiasis ## Footnote Smokers have a 2-5 fold increased risk.
132
What are the types of bladder malignancies?
Urothelial carcinoma (>90%), squamous cell carcinoma (1-7%), adenocarcinoma (2%) ## Footnote Urothelial carcinomas may be solitary or multifocal.
133
What does TNM staging stand for?
Tumor, Node, Metastasis ## Footnote It is a classification system for cancer staging.
134
What is the prognosis for T1 bladder cancer?
90% ## Footnote Prognosis decreases as the stage increases.
135
What are common risk factors for urothelial carcinoma?
Smoking, exposure to aniline dyes, rubber manufacture, cyclophosphamide ## Footnote Smoking is the most important risk factor in western countries.
136
What are the presenting symptoms of bladder cancer?
Painless macroscopic haematuria ## Footnote Up to 10% of females over 50 with microscopic haematuria may have malignancy.
137
What is benign prostatic hyperplasia (BPH)?
A common condition seen in older men characterized by lower urinary tract symptoms ## Footnote Around 50% of 50-year-old men will have evidence of BPH.
138
What are the risk factors for BPH?
Age, ethnicity (black > white > Asian) ## Footnote BPH symptoms increase with age.
139
What are the voiding symptoms of BPH?
Weak flow, straining, hesitancy, terminal dribbling, incomplete emptying ## Footnote These are obstructive symptoms.
140
What are the storage symptoms of BPH?
Urgency, frequency, nocturia, post-micturition dribbling ## Footnote These are irritative symptoms.
141
What is the International Prostate Symptom Score (IPSS)?
A tool for classifying the severity of lower urinary tract symptoms ## Footnote Scores range from 0-35, indicating mild to severe symptoms.
142
What are the management options for BPH?
Watchful waiting, alpha-1 antagonists, 5 alpha-reductase inhibitors, surgery (TURP) ## Footnote Combination therapy may be considered for moderate-to-severe symptoms.
143
What is TURP syndrome?
A rare complication of transurethral resection of the prostate caused by irrigation with glycine ## Footnote It results in hyponatremia and can present with CNS symptoms.
144
What are the risk factors for developing TURP syndrome?
Surgical time > 1 hr, height of bag > 70cm, resected > 60g, large blood loss ## Footnote These factors increase the likelihood of systemic absorption of glycine.
145
What are the fluid requirements for maintenance in adults according to NICE?
25-30 ml/kg/day of water, 1 mmol/kg/day of potassium, sodium, chloride, 50-100 g/day of glucose ## Footnote Adjustments may be needed based on medical history.
146
What is the commonest cause of end-stage renal disease (ESRD) in the western world?
Diabetic nephropathy ## Footnote 33% of patients with type 1 diabetes mellitus have diabetic nephropathy by age 40.
147
What are the stages of diabetic nephropathy?
Stage 1: Hyperfiltration, Stage 2: Silent phase, Stage 3: Incipient nephropathy, Stage 4: Overt nephropathy, Stage 5: End-stage renal disease ## Footnote Progression occurs at different rates in type 1 and type 2 diabetes.
148
What is the management for diabetic nephropathy?
Dietary protein restriction, tight glycaemic control, BP control, ACE inhibitors, control dyslipidaemia ## Footnote Annual screening with urinary albumin:creatinine ratio is recommended.
149
What is persistent proteinuria in the context of nephropathy?
Albumin excretion > 300 mg/day, dipstick positive ## Footnote Persistent proteinuria is a key indicator in evaluating kidney function in nephropathy.
150
What is the typical GFR in Stage 5 end-stage renal disease?
Typically < 10 ml/min ## Footnote At this stage, renal replacement therapy is needed.
151
How do the progression timelines of type 1 and type 2 diabetes mellitus differ?
Type 1 progresses through stages typically, while type 2 may progress quickly to later stages ## Footnote Some patients with type 2 diabetes mellitus (T2DM) may experience rapid progression.
152
What are the first-line treatments for venous thromboembolism (VTE) according to the 2020 NICE guidelines?
Direct oral anticoagulants (DOACs) ## Footnote This includes their use as interim anticoagulants before a definite diagnosis.
153
What is the two-level DVT Wells score used for?
To assess the likelihood of deep vein thrombosis (DVT) ## Footnote It includes various clinical features with assigned points.
154
What score indicates a DVT is likely according to the two-level DVT Wells score?
2 points or more ## Footnote This score helps determine further diagnostic steps.
155
What should be done if a DVT is 'likely' based on the Wells score?
A proximal leg vein ultrasound scan within 4 hours ## Footnote If positive, anticoagulant treatment should start immediately.
156
What is the recommended action if a DVT is 'unlikely'?
Perform a D-dimer test ## Footnote If D-dimer is positive, follow up with a proximal leg vein ultrasound scan.
157
What type of D-dimer tests does NICE recommend?
Either point-of-care (finger prick) or laboratory-based tests ## Footnote Age-adjusted cut-offs should be used for patients > 50 years old.
158
What was the historical method for VTE management before the introduction of DOACs?
Warfarin, often preceded by heparin until INR was stable ## Footnote The emergence of DOACs has transformed modern management.
159
According to the 2020 guidelines, what should be the first-line anticoagulant offered after a DVT diagnosis?
Apixaban or rivaroxaban ## Footnote DOACs are now preferred over low-molecular weight heparin.
160
What is the minimum duration for anticoagulation in VTE management?
At least 3 months ## Footnote Duration may vary based on whether the VTE was provoked or unprovoked.
161
What characterizes a provoked VTE?
Due to an obvious precipitating event ## Footnote Example: immobilisation following major surgery.
162
What is the ORBIT score used for?
To assess the risk of bleeding ## Footnote This helps determine the duration of anticoagulant therapy.
163
What are common clinical features of a DVT?
Lower limb pain, swelling, erythema, pitting oedema, distension of superficial veins ## Footnote These symptoms are crucial for diagnosis.
164
What is the common condition diagnosed in up to 30,000 men each year in the UK?
Prostate cancer ## Footnote Prostate cancer is the most common cancer in adult males in the UK.
165
What is a common symptom of metastatic prostate cancer?
Bone pain
166
What are some symptoms of locally advanced prostate cancer?
Pelvic pain, urinary symptoms
167
What diagnostic tests are used for prostate cancer?
* Prostate specific antigen measurement * Digital rectal examination * Trans rectal ultrasound (+/- biopsy) * MRI/CT and bone scan for staging
168
What is the normal upper limit for prostate specific antigen (PSA)?
4 ng/ml
169
What may cause false positives in PSA testing?
* Prostatitis * Urinary tract infection (UTI) * Benign prostatic hyperplasia (BPH) * Vigorous digital rectal examination (DRE)
170
What percentage of free: total PSA suggests cancer?
<20%
171
What is the most common pathology type found in prostate cancer?
Adenocarcinoma (95%)
172
What grading system is used for prostate cancer and how is it calculated?
Gleason grading system; two grades are awarded, added together to give the Gleason score
173
What does a Gleason score of 2 indicate?
Best prognosis
174
What is the first site of lymphatic spread in prostate cancer?
Obturator nodes
175
What treatment options are available for low-risk prostate cancer?
* Watch and wait * Radiotherapy * Surgery (Radical prostatectomy) * Hormonal therapy
176
What is the preferred option for low-risk men according to NICE?
Active surveillance
177
What are the risk factors for developing prostate cancer? (4)
* Increasing age * Obesity * Afro-Caribbean ethnicity * Family history (5-10%)
178
What are potential symptoms of localized prostate cancer?
* Bladder outlet obstruction * Hematuria * Hematospermia * Pain (back, perineal, testicular)
179
What is the traditional investigation for suspected prostate cancer?
Transrectal ultrasound-guided biopsy (TRUS)
180
What is the first-line investigation for suspected clinically localized prostate cancer?
Multiparametric MRI
181
What complications can arise from TRUS biopsy?
* Sepsis (1%) * Pain (lasting >= 2 weeks in 15%) * Fever (5%) * Hematuria and rectal bleeding
182
What is the management for renal stones less than 5mm?
Watchful waiting
183
What is the treatment for renal stones measuring 10-20 mm?
* Shockwave lithotripsy * Ureteroscopy
184
What percentage of men with a PSA of 4-10 ng/ml will have prostate cancer?
33%
185
What is a key aim of treating advanced prostate cancer?
Reducing androgen levels
186
What is the role of GnRH agonists in prostate cancer treatment?
Initially increase testosterone levels before reducing them to castration levels
187
What is a common side effect of radical prostatectomy?
Erectile dysfunction
188
What is the function of bicalutamide in prostate cancer treatment?
Non-steroidal anti-androgen that blocks the androgen receptor
189
What is the recommended PSA level threshold for men aged 50-59?
> 3.5 ng/ml
190
What urinary condition may raise PSA levels?
Benign prostatic hyperplasia (BPH)
191
What is the management for stones larger than 20 mm?
Percutaneous nephrolithotomy
192
What is the typical management for patients with renal colic?
NSAID analgesia
193
What does the Likert scale score of 3 or higher indicate?
Offer a multiparametric MRI-influenced prostate biopsy
194
What is the composition of struvite stones?
Magnesium, ammonium, and phosphate
195
What is the effect of urinary pH on stone formation?
Varies by stone type; e.g., uric acid stones form in acidic urine
196
What is an important consideration when prescribing NSAIDs for renal colic?
Increased risk of cardiovascular events
197
What are the potential complications of radiotherapy for prostate cancer?
* Radiation proctitis * Rectal malignancy * Increased risk of bladder, colon, and rectal cancer
198
What is the typical management for ureteric stones less than 10 mm?
Shockwave lithotripsy +/- alpha blockers
199
What should be done if a patient with renal stones shows signs of infection?
Immediate CT KUB
200
What is the significance of age-adjusted PSA levels?
Helps in determining the need for further investigation based on age
201
What is the procedure of rolithotomy used for?
Access to the renal collecting system ## Footnote Involves intra corporeal lithotripsy or stone fragmentation and removal of stone fragments.
202
What percentage of the general population may experience hypercalciuria leading to calcium stones?
5-10% ## Footnote This condition is a significant risk factor for the formation of calcium stones.
203
List three prevention strategies for renal stones.
* High fluid intake * Add lemon juice to drinking water * Limit salt intake
204
Which substance may be beneficial in preventing calcium stones according to NICE?
Potassium citrate ## Footnote It may help in managing calcium levels in urine.
205
What is the effect of cholestyramine on urinary oxalate secretion?
Reduces urinary oxalate secretion ## Footnote This is particularly relevant for preventing oxalate stones.
206
What medication is used to treat uric acid stones?
Allopurinol ## Footnote It helps in reducing uric acid levels in the body.
207
Identify two risk factors for the formation of renal stones.
* Dehydration * Hypercalciuria
208
Which condition is associated with urate stones due to loss of bicarbonate and fluid?
Ileostomy ## Footnote This results in acidic urine, promoting uric acid precipitation.
209
Name a drug that promotes the formation of calcium stones.
Loop diuretics ## Footnote Other drugs include steroids, acetazolamide, and theophylline.
210
What is the radiographic appearance of calcium oxalate stones?
Opaque ## Footnote They account for 40% of renal stones.
211
What type of renal stone has a 'ground-glass' appearance on X-ray?
Cystine stones ## Footnote These stones constitute about 1% of renal stones.
212
Fill in the blank: Stag-horn calculi develop in _______ urine.
Alkaline ## Footnote They are composed of struvite and involve the renal pelvis.
213
What is the frequency of occurrence for mixed calcium oxalate/phosphate stones?
25% ## Footnote These stones are also opaque on radiographs.
214
True or False: Urate stones are radio-lucent.
True ## Footnote They account for 5-10% of renal stones.
215
What are the components of stag-horn calculi?
Struvite (ammonium magnesium phosphate, triple phosphate) ## Footnote They are often associated with infections by Ureaplasma urealyticum and Proteus.
216
Which diuretic can prevent calcium stones by increasing distal tubular calcium resorption?
Thiazides ## Footnote They help in reducing the risk of calcium stone formation.
217
What are the two primary conditions that account for 90% of cases of hypercalcaemia?
1. Primary hyperparathyroidism 2. Malignancy
218
What is the commonest cause of hypercalcaemia in non-hospitalised patients?
Primary hyperparathyroidism
219
What is the commonest cause of hypercalcaemia in hospitalised patients?
Malignancy
220
What are some processes by which malignancy can cause hypercalcaemia?
* PTHrP from the tumour (e.g. squamous cell lung cancer) * Bone metastases * Myeloma (due to increased osteoclastic bone resorption)
221
What is the key investigation for patients with hypercalcaemia?
Measuring parathyroid hormone levels
222
List other causes of hypercalcaemia.(10)
* Sarcoidosis * Vitamin D intoxication * Acromegaly * Thyrotoxicosis * Milk-alkali syndrome * Thiazides * Calcium-containing antacids * Dehydration * Addison's disease * Paget's disease of the bone
223
What mnemonic is used to remember the features of hypercalcaemia?
'Bones, stones, groans, and psychic moans'
224
What are some ECG changes associated with hyperkalaemia?
* Tall-tented T waves * Small P waves * Widened QRS leading to a sinusoidal pattern * Asystole
225
What are the causes of hyperkalaemia? (6)
* Acute kidney injury * Drugs (e.g. potassium-sparing diuretics, ACE inhibitors) * Metabolic acidosis * Addison's disease * Rhabdomyolysis * Massive blood transfusion
226
What foods are high in potassium?
* Salt substitutes (contain potassium) * Bananas * Oranges * Kiwi fruit * Avocado * Spinach * Tomatoes
227
True or False: IV calcium gluconate lowers serum potassium levels.
False
228
What is the European Resuscitation Council's classification of hyperkalaemia based on potassium levels?
* Mild: 5.5 - 5.9 mmol/L * Moderate: 6.0 - 6.4 mmol/L * Severe: ≥ 6.5 mmol/L
229
What is the preferred treatment for severe hypocalcaemia?
IV calcium replacement with calcium gluconate
230
What are the features of hypocalcaemia?
* Tetany * Perioral paraesthesia * Prolonged QT interval on ECG
231
What signs are associated with hypocalcaemia?
* Trousseau's sign * Chvostek's sign
232
What can cause hypokalaemia with alkalosis?
* Vomiting * Thiazide and loop diuretics * Cushing's syndrome * Conn's syndrome
233
What is the treatment for magnesium deficiency?
* <0.4 mmol/L or tetany, arrhythmias, seizures: IV magnesium replacement * >0.4 mmol/L: Oral magnesium salts
234
What are the causes of hyponatraemia?
* Water excess * Sodium depletion
235
What is the principle management for acute severe hyponatraemia?
Hypertonic saline (typically 3% NaCl)
236
What are the complications of over-correction in hyponatraemia?
Osmotic demyelination syndrome (central pontine myelinolysis)
237
What is the most common bladder cancer?
Urothelial (transitional cell) carcinoma
238
What risk factors increase the likelihood of bladder cancer?
* Smoking * Exposure to hydrocarbons * Chronic bladder inflammation (e.g. Schistosomiasis)
239
What percentage of bladder malignancies are urothelial carcinomas?
>90%
240
What is the typical age range for males affected by bladder cancer?
50 to 80 years
241
What is the most common type of bladder cancer?
Transitional cell carcinoma (TCC) ## Footnote TCC accounts for 90% of bladder cancers.
242
What proportion of TCCs have a papillary growth pattern?
Up to 70% ## Footnote Papillary growth patterns are typically associated with better prognosis.
243
What is the prognosis for T3 bladder cancer?
30% (or higher) risk of regional or distant lymph node metastasis
244
What does T0 in TNM staging indicate?
No evidence of tumour
245
What is the definition of Ta in TNM staging?
Non invasive papillary carcinoma
246
What is the most common presentation of bladder cancer?
Painless, macroscopic haematuria (85%)
247
What is the recommended management for superficial bladder lesions?
TURBT in isolation
248
What is the prognosis for T2 bladder cancer?
60%
249
What is the term for non-visible haematuria?
Non-visible haematuria ## Footnote This term is used to describe microscopic or dipstick positive haematuria.
250
List three causes of transient non-visible haematuria.
* Urinary tract infection * Menstruation * Vigorous exercise
251
What is the test of choice for detecting haematuria?
Urine dipstick
252
What criteria define persistent non-visible haematuria?
Blood present in 2 out of 3 samples tested 2-3 weeks apart
253
What are the NICE urgent cancer referral guidelines for patients aged >= 45 years?
Unexplained visible haematuria without urinary tract infection or visible haematuria that persists or recurs after successful treatment of urinary tract infection
254
What is IgA nephropathy also known as?
Berger's disease
255
What is the classical presentation of IgA nephropathy?
Macroscopic haematuria in young people following an upper respiratory tract infection
256
What is the common histological subtype of renal cell carcinoma?
Clear cell carcinoma (75-85% of tumours)
257
What is the classical triad of renal cell carcinoma?
* Haematuria * Loin pain * Abdominal mass
258
What are the T category criteria for renal cell carcinoma?
* T1: Tumour ≤ 7 cm and confined to the kidney * T2: Tumour > 7 cm and confined to the kidney * T3: Tumour extends into major veins or perinephric tissues * T4: Tumour invades beyond Gerota's fascia
259
What is the management for a T1 renal cell carcinoma?
Partial nephrectomy
260
What is a hydrocele?
Accumulation of fluid within the tunica vaginalis
261
What distinguishes a communicating hydrocele from a non-communicating hydrocele?
Communicating: patency of the processus vaginalis; Non-communicating: excessive fluid production
262
What is a varicocele?
Abnormal enlargement of the testicular veins
263
What is the most common cause of scrotal swellings seen in primary care?
Epididymal cysts
264
What is the management for testicular malignancy?
Orchidectomy via an inguinal approach
265
What is the commonest age group for testicular torsion?
Around puberty
266
What is Stauffer syndrome associated with?
Renal cell cancer ## Footnote Typically presents as cholestasis/hepatosplenomegaly.
267
What are the features of a hydrocele?
* Soft, non-tender swelling of the hemi-scrotum * Transilluminates with a pen torch
268
What is the management for an infantile hydrocele that does not resolve spontaneously?
Repair by age of 1-2 years
269
What is the typical location for varicoceles?
Typically occur on the left side ## Footnote This is because the testicular vein drains into the renal vein.
270
What is a potential presenting feature of renal cell carcinoma?
Varicoceles ## Footnote Affected testis may be smaller, and bilateral varicoceles may affect fertility.
271
What is the standard treatment for testicular malignancy?
Orchidectomy via an inguinal approach ## Footnote This allows high ligation of the testicular vessels and avoids exposure of another lymphatic field to the tumour.
272
What is the most common age group for testicular torsion?
Young teenagers ## Footnote Most commonly occurs in males aged between 10 and 30 years, with peak incidence at 13-15 years.
273
What is the treatment for testicular torsion?
Prompt surgical exploration and testicular fixation ## Footnote Can be achieved using sutures or by placement of the testis in a Dartos pouch.
274
How are varicoceles generally managed?
Usually managed conservatively ## Footnote Surgery or radiological management may be considered if there are concerns about testicular function or infertility.
275
How are epididymal cysts excised?
Using a scrotal approach
276
What is the management approach for hydroceles in children?
Inguinal approach to ligate the processus vaginalis ## Footnote The underlying pathology is a patent processus vaginalis.
277
What is the most common malignancy in men aged 20-30 years?
Testicular cancer
278
What percentage of testicular cancer cases are germ-cell tumours?
Around 95%
279
What are the two main types of germ cell tumours?
* Seminomas * Non-seminomas (including embryonal, yolk sac, teratoma, choriocarcinoma)
280
What is the peak incidence age for teratomas and seminomas?
* Teratomas: 25 years * Seminomas: 35 years
281
What are some risk factors for testicular cancer?
* Infertility * Cryptorchidism * Family history * Klinefelter's syndrome * Mumps orchitis
282
What is the most common presenting symptom of testicular cancer?
A painless lump
283
What may occur due to an increased oestrogen:androgen ratio in testicular cancer?
Gynaecomastia
284
What is the first-line diagnostic tool for testicular cancer?
Ultrasound
285
What are the treatment options for testicular cancer?
* Orchidectomy * Chemotherapy * Radiotherapy ## Footnote Treatment depends on whether the tumour is a seminoma or a non-seminoma.
286
What is the prognosis for seminomas at Stage I?
Around 95% 5-year survival
287
What is the prognosis for teratomas at Stage I?
Around 85% 5-year survival
288
What is acute epididymitis?
Acute inflammation of the epididymis, often involving the testis, usually caused by bacterial infection
289
What are the usual infections causing epididymitis in men under 35?
* Gonorrhoea * Chlamydia
290
What is the typical symptom of testicular torsion?
Severe pain of sudden onset
291
What sign is lost in testicular torsion?
Cremasteric reflex
292
What is a hydrocele?
A mass that transilluminates, usually possible to 'get above' on examination
293
What is the treatment for hydrocele in adults?
Lords or Jabouley procedure
294
What are the small vestigial remnants associated with testicular torsion?
* Appendix testis * Appendix epididymis
295
What is the 'blue-dot' sign associated with?
Appendix testis torsion
296
What is the usual age group for appendix testis torsion?
Boys aged 8-11 years
297
What is the management approach for suspected appendix testis torsion?
Exploratory operation to exclude classic testicular torsion
298
What is aortic dissection?
A rare but serious cause of chest pain
299
What is the primary pathophysiological change in aortic dissection?
Tear in the tunica intima of the wall of the aorta
300
What is the most important risk factor associated with aortic dissection?
Hypertension
301
Name three associations of aortic dissection.
* Trauma * Bicuspid aortic valve * Marfan's syndrome
302
What is a common symptom of aortic dissection?
Chest or back pain
303
How is the pain in aortic dissection typically described?
Severe and 'sharp', 'tearing' in nature
304
What is the difference in pain presentation between type A and type B aortic dissection?
Chest pain is more common in type A; upper back pain is more common in type B
305
What are some physical exam findings in aortic dissection?
* Pulse deficit * Variation in systolic blood pressure between arms * Aortic regurgitation
306
What classification system is used for aortic dissection?
Stanford and DeBakey classification
307
What is the difference between type A and type B in the Stanford classification?
* Type A: Involves ascending aorta * Type B: Involves descending aorta
308
What are the three types of aortic dissection in the DeBakey classification?
* Type I: Originates in ascending aorta, propagates distally * Type II: Confined to ascending aorta * Type III: Originates in descending aorta
309
What is a common presentation of chronic kidney disease?
Usually asymptomatic, diagnosed via abnormal urea and electrolyte results
310
List some possible symptoms of late-stage chronic kidney disease. (8)
* Oedema * Polyuria * Lethargy * Pruritus * Anorexia * Insomnia * Nausea and vomiting * Hypertension
311
What defines hypertension?
Chronically raised blood pressure, typically above 140/90 mmHg
312
What is the normal blood pressure range for healthy individuals?
Between 90/60 mmHg and 140/90 mmHg
313
What percentage of hypertension cases are classified as primary or essential?
Around 90-95%
314
Name three causes of secondary hypertension.
* Renal disease * Endocrine disorders * Other causes (e.g., pregnancy, medications)
315
What symptoms may indicate very high blood pressure?
* Headaches * Visual disturbance * Seizures
316
What is the recommended method for diagnosing longstanding hypertension?
Using 24-hour blood pressure monitors
317
What should be checked to assess for end-organ damage in hypertension?
* Fundoscopy * Urine dipstick * ECG
318
What are the common drug classes used to treat hypertension?
* ACE inhibitors * Calcium channel blockers * Thiazide-type diuretics * Angiotensin II receptor blockers (A2RB)
319
What is a common side effect of ACE inhibitors?
Cough
320
What is the first-line treatment for patients under 55 years with hypertension?
ACE inhibitor or angiotensin receptor blocker
321
What lifestyle changes are recommended for managing hypertension? (7)
* Low salt diet * Reduced caffeine intake * Stop smoking * Drink less alcohol * Eat a balanced diet * Exercise more * Lose weight
322
What is the criteria for Stage 1 hypertension according to NICE?
Clinic BP >= 140/90 mmHg and subsequent ABPM or HBPM average >= 135/85 mmHg
323
What is the criteria for Stage 2 hypertension according to NICE?
Clinic BP >= 160/100 mmHg and subsequent ABPM or HBPM average >= 150/95 mmHg
324
What is the recommended action if a patient's blood pressure is >= 180/120 mmHg?
Admit for specialist assessment
325
What is the protocol for home blood pressure monitoring (HBPM)?
* Two consecutive measurements at least 1 minute apart * Record twice daily for at least 4 days
326
True or False: Blood pressure readings in both arms should be measured when diagnosing hypertension.
True
327
Fill in the blank: NICE recommends that antihypertensive drug treatment should be considered for adults under 60 with stage 1 hypertension and an estimated 10-year risk below _______.
10%
328
What is the first-line treatment for hypertension in patients with diabetes mellitus?
ACE inhibitor or Angiotensin receptor blocker (ACE-i or ARB) ## Footnote ACE inhibitors are preferred unless contraindicated.
329
When should angiotensin receptor blockers be used instead of ACE inhibitors?
When ACE inhibitors are not tolerated (e.g., due to cough) ## Footnote This indicates a patient-specific response to medication.
330
What is the recommended first-line treatment for patients aged 55 or of black African or African-Caribbean origin?
Calcium channel blocker (C) ## Footnote ACE inhibitors have reduced efficacy in these populations.
331
If a patient is already taking an ACE-i or ARB, what should be added next for hypertension treatment?
Calcium channel blocker or a thiazide-like diuretic ## Footnote This is part of step 2 treatment.
332
What is the third step in hypertension treatment if a patient is already on (A + C)?
Add a thiazide-like diuretic (D) ## Footnote This completes the (A + C + D) regimen.
333
What defines step 4 treatment in hypertension management according to NICE?
Resistant hypertension ## Footnote It involves adding a fourth drug or seeking specialist advice.
334
What should be confirmed before proceeding to step 4 treatment?
Elevated clinic BP with ABPM or HBPM and assess for postural hypotension ## Footnote This ensures accurate diagnosis before further treatment.
335
What is the blood pressure target for patients under 80 years using clinic BP?
140/90 mmHg ## Footnote This is the guideline target for managing hypertension.
336
What is the most common cause of secondary hypertension?
Primary hyperaldosteronism (including Conn's syndrome) ## Footnote This condition affects 5-10% of patients diagnosed with hypertension.
337
What renal conditions may increase blood pressure?
* Glomerulonephritis * Pyelonephritis * Adult polycystic kidney disease * Renal artery stenosis ## Footnote These conditions are significant contributors to secondary hypertension.
338
Name an endocrine disorder that can lead to increased blood pressure.
Phaeochromocytoma ## Footnote Other disorders include Cushing's syndrome, Liddle's syndrome, congenital adrenal hyperplasia, and acromegaly.
339
List some drug causes of secondary hypertension.
* Steroids * Monoamine oxidase inhibitors * Combined oral contraceptive pill * NSAIDs * Leflunomide ## Footnote These medications can contribute to elevated blood pressure.
340
What are the causes of primary hyperparathyroidism?
* Solitary adenoma (85%) * Hyperplasia (10%) * Multiple adenoma (4%) * Carcinoma (1%) ## Footnote Most cases are due to a solitary adenoma.
341
What mnemonic helps remember the symptomatic features of primary hyperparathyroidism?
'Bones, stones, abdominal groans and psychic moans' ## Footnote This includes polydipsia, depression, nausea, and more.
342
What are common associations with primary hyperparathyroidism?
* Hypertension * Multiple endocrine neoplasia: MEN I and II ## Footnote These associations are important for diagnosis and management.
343
What investigations are used for primary hyperparathyroidism?
* Blood tests (raised calcium, low phosphate) * PTH levels * Technetium-MIBI subtraction scan * X-ray findings (pepperpot skull, osteitis fibrosa cystica) ## Footnote These tests help confirm the diagnosis.
344
What is the definitive management for primary hyperparathyroidism?
Total parathyroidectomy ## Footnote This is the surgical treatment of choice.
345
Under what conditions can conservative management be offered for primary hyperparathyroidism?
If calcium level is < 0.25 mmol/L above normal, patient is > 50 years, and no end-organ damage ## Footnote Conservative management may delay surgery.
346
What is cinacalcet?
A calcimimetic used for patients not suitable for surgery ## Footnote It mimics calcium's action on tissues.
UKMLA Prep
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