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Ace It: Medical Specialties Rheumatology – Sunday 13 February Urology Common Urology SBAs26 Year olLeukocytes and nitrites. Last menstural period 6 weeks ago.ne dip positive for What is the most appropriatenext step to treat the infection? A. Cystoscopy B. Trimethoprim C. Grape fruit juice D. Nitrofurantoin E. Tazocin26 Year olLeukocytes and nitrites. Last menstural period 6 weeks ago.ne dip positive for What is the most appropriatenext step to treat the infection? A. Cystoscopy B. Trimethoprim C. Grape fruit juice D. Nitrofurantoin E. Tazocin Urinary tract infections Dysuria, Polyuria, Urgency, cloudy/offensive urine, lower Abdo pain, fever, confusion More common in females. Shorter urethra. Men & Non Pregnant women: 1. Trimethoprim 2. Nitrofurantoin Pregnant women: 1. Nitrofurantoin 2. Amoxicillin Avoid Trimethoprimin pregnancy, especially first term –> Teratogenic Folate antagonist–> Neural tube defects Avoid Nitrofurantoinat term–> Neonatal haemolysis16 Year old boy attends A&E with 1 hour history of very painful and swollen left testicle. He On Examination: Left testicle retracted upward, reddened scrotal skin. Attemptingto elevate the testis causes severe pain. What is the most likely diagnosis? A. Prostatitis B. T esticular torsion C. Hydrocele D. Varicocele E. Epididymo-orchitis16 Year old boy attends A&E with 1 hour history of very painful and swollen left testicle. He On Examination: Left testicle retracted upward, reddened scrotal skin. Attemptingto elevate the testis causes severe pain. What is the most likely diagnosis? A. Prostatitis B. T esticular torsion C. Hydrocele D. Varicocele E. Epididymo-orchitis T esticular T orsion Suspected Testicular Torsion = EMERGENCY !!! Requires emergency surgical intervention Twisted spermatic cord = ischaemia & Necrosis Ischaemic time for testis 4-8h Younger male 10-30 Years old Severe sudden onset testicular pain Sometimes Nausea, Vomiting Testis is tender and not eased by elevation – Prehn’s sign Loss of cremasteric reflex – stroking inner thigh causes cremaster muscle to contract, pulling ipsilateral testicle up.Patient is taken ASAP to theatre, Left testicular torsion is confirmed on surgical exploration What is the management? A. Left orchidopexy B. Bilateral orchidectomy C. Left orchidectomy D. Bilateral orchidopexy E. Right orchidectomyPatient is taken ASAP to theatre, Left testicular torsion is confirmed on surgical exploration What is the management? A. Left orchidopexy B. Bilateral orchidectomy C. Left orchidectomy D. Bilateral orchidopexy E. Right orchidectomy Patient with medical history of cystic fibrosis presents to GP with painless lump in right testis, on examinationthe GP can get above it and feel the top surface of a round smooth lump adjacent to and separatefrom main body of the testis. What is the likely diagnosis? A. Epidydimal cyst B. Hydrocele C. T esticular torsion D. Varicocele E. Epididymo-orchitis Patient with medical history of cystic fibrosis presents to GP with painless lump in right testis, on examinationthe GP can get above it and feel the top surface of a round smooth lump adjacent to and separatefrom main body of the testis. What is the likely diagnosis? A. Epidydimal cyst B. Hydrocele C. T esticular torsion D. Varicocele E. Epididymo-orchitis Scrotal Swelling History Management Torsion Severe sudden pain, +/-Nausea & Vomiting, swollen tender Surgical Exploration, Bilateral testis retracted upwards. Pain worse on elevating testis orchidopexy Inguinal hernia Cant get above it. Superior & Medial to pubic tubercle Surgical repair +/- Cough impulse/ reducible Epididymo-orchitis Dysuria, urethral discharge, pain eased by elevating testis. Antibiotics, Ceftriaxone & Due to STI (Chlamydia) or UTI Doxycycline. Rest. Analgesia Epididymal cyst Can get above it. Most common cause of scrotal swelling. Conservative usually, just leave it Painless. Separate to body of testis. Posterior to testis. alone. Surgery if symptomatic Cystic fibrosis, polycystic kidney disease Varicocele Asymptomatic enlargement of testicular veins “bag of Conservative. Surgery if worms”. Most common left side. Subfertility. symptomatic/ infertility Hydrocele Can get above it. Build up of fluid within tunica vaginalis.Conservative/Surgery, USS to rule Transilluminates with pen torch. out testicular cancer. Testicular tumour Infertility x3 risk. Painless lump. Hydrocele. GynaecomastiaOrchidectomy. 95% Germ cell tumours. Seminomas & non seminomas Chemo/Radiotherapy. 43 year old male presents to A&E with severe intermittent lion to groin pain, has been coming in waves over the past week but now very severe. Urine dip stick positive for blood. The patient is in severe pain. Whats the best initial treatment? A. Oxybutynin B. IV Paracetamol C. Tamsulosin D. IM Diclofenac E. Co-Codamol 43 year old male presents to A&E with severe intermittent lion to groin pain, has been coming in waves over the past week but now very severe. Urine dip stick positive for blood. The patient is in severe pain. Whats the best initial treatment? A. Oxybutynin B. IV Paracetamol C. Tamsulosin D. IM Diclofenac E. Co-Codamolcoming in waves of the past week but now very severe. Urine dip stick positive for blood. Which method of testing is likely to be diagnostic? A. Contrast CT KUB B. Abdominal MRI C. Abdominal USS D. Urodynamic studies E. Non – contrast CT KUBcoming in waves of the past week but now very severe. Urine dip stick positive for blood. Which method of testing is likely to be diagnostic? A. Contrast CT KUB B. Abdominal MRI C. Abdominal USS D. Urodynamic studies E. Non – contrast CT KUB Renal Stones Parenteral analgesia e.g. IM Diclofenac (NSAID) Non-Contrast CT KUB Stones < 5 mm usually pass on their own spontaneouslywithin 4 weeks Shockwave Lithotripsy(ultrasonicenergy) Nephrolithotomy(Surgical scope inserted into kidney) Signs of infection (fever) + Stone causing ureteric obstruction = EMERGENCY Urgent surgical decompression(nephrostomy, ureteric catheter stenting)+ IV Antibiotics 43 year old male presents to A&E with severe intermittent lion to groin pain, has been coming in waves over the past week but now very severe. Urine dip stick positive for blood. IM diclofenBlood test: Calcium 2.91 (2.1 – 2.6)UB is planned. What medication can target the abnormal results to reduce future episodes? A. Bicarbonate B. Cholestyramine C. Pyridoxine D. Bendroflumethiazide E. Allopurinol 43 year old male presents to A&E with severe intermittent lion to groin pain, has been coming in waves over the past week but now very severe. Urine dip stick positive for blood. IM diclofenBlood test: Calcium 2.91 (2.1 – 2.6)UB is planned. What medication can target the abnormal results to reduce future episodes? A. Bicarbonate B. Cholestyramine C. Pyridoxine D. Bendroflumethiazide E. Allopurinol Renal Stones Prevention Avoid Dehydration, high oxalate/uric acid foods Risk factors: Hypercalcaemia, Hypercalciuria Calcium oxalate 85% Calcium Phosphate10% Uric Acid 5% Other- Cystine, Struvite. Calcium stones due to Hypercalciuria(10% of population) -> Thiazide diuretics Oxalate stones -> Cholestyramine, pyridoxine Uric Acid stones -> Allopurinol, Oral bicarbonate for urinary alkalinization68 Year old man present to GP with weak urinary stream, straining and dribbling. He denies any urgencprostatic hyperplasia and already taking an alpha-1-antagonist.d with benign His prostate is enlarged and PSA is 2.1 ng/ml What is the best next medication to prescribe? A. Tamsulosin B. Finasteride C. Desmopressin D. T olterodine E. Sildenafil68 Year old man present to GP with weak urinary stream, straining and dribbling. He denies any urgencprostatic hyperplasia and already taking an alpha-1-antagonist.d with benign His prostate is enlarged and PSA is 2.1 ng/ml What is the best next medication to prescribe? A. Tamsulosin B. Finasteride C. Desmopressin D. T olterodine E. SildenafilBenign Prostatic Hyperplasia (BPH) 50% 50 Year old Males and 80% 80 Year old Males have BPH More common in Afro-Caribbean, Asian ethnicity Symptoms: Voiding (Obstructive): Weak flow, straining, dribbling Storage (Irritative): Urgency, increased frequency, Nocturia Management: 1. Conservative 2. Alpha-1-Antagonist (Tamsulosin, Alfuzosin) • 5 Alpha-Reductase Inhibitors (Finasteride) • Anticholinergic (Tolterodine, Oxybutynin) • Surgery - Transurethral resection of prostate (TURP)76 Year old male presents to GP with 3 month history of urinary hesitancy and occasional visiblehaematuria.On digital rectal examination, an enlarged nodular prostate is felt. PSA 15.4 ng/mL (0-5.5 ng/mL) What is the best next investigationfor the suspected diagnosis? A. Trans-perineal biopsy of prostate B. Positron emission tomography C. Multiparametric MRI D. Pelvic CT scan E. Trans-rectal ultrasound biopsy76 Year old male presents to GP with 3 month history of urinary hesitancy and occasional visiblehaematuria.On digital rectal examination, an enlarged nodular prostate is felt. PSA 15.4 ng/mL (0-5.5 ng/mL) What is the best next investigationfor the suspected diagnosis? A. Trans-perineal biopsy of prostate B. Positron emission tomography C. Multiparametric MRI D. Pelvic CT scan E. Trans-rectal ultrasound biopsy Prostate Cancer Older male, Afro-Caribbean, Family hx Hesitancy, urinary retention, Haematuria, Haematospermia, Pain Digital Rectal Examination: Hard, Nodular, Asymmetrical enlargement, loss of median sulcus Investigations: PSA, MRI, trans rectal USS biopsy 95% Adenocarcinoma Gleason scoring 2-10. (10 is worst) Treatment: Active surveillance, Hormonal/Surgery castration, surgical removal of prostate + Radiotherapy PSA Normal upper limit 4ng/mL (upper limit increase with age) Use result in context of symptoms, Digital rectal exam Free PSA:Total PSA <20% indicated cancer Causes of raised PSA: Exercise, intercourse, BPH, ?Digital rectal exam, UTI Poor sensitivity and specificity. Monitoring PSA levels over time can be useful ENT Thank you. Now over to Abdullah for ENTThe E in ENT stands for ear…. Or so we think This is what happens when you pick at your ear a little too hardWhich CN is responsible for hearing and balance • Cranial Nerve 9 • Cranial Nerve 6 • Cranial Nerve 10 • Cranial Nerve 8 • Cranial Nerve 7• Cranial Nerve 9 • Cranial Nerve 6 • Cranial Nerve 10 • Cranial Nerve 8 • Cranial Nerve 7Rinne’s and Weber’s Interpretation Normal Conductive Sensorineural Total unilateral deafness deafness hearing loss “dead ear” Rinne Positive Negative Positive Negative Air > Bone Bone > Air Air> bone Bone > Air Weber Midline Lateralises to Lateralises to Lateralises to deaf ear (same normal ear normal ear side) (opposite ear) (opposite side)Weber's lateralises to the right ear . Rinne’s positive in the left while negative in the right ear . What is the cause? • Left ear - Noise damage • Left ear - Ruptured ear drum • Right ear - Impacted earwax • Right ear - Presbycusis • Left ear – otitis mediaWeber's lateralises to the right ear. Rinne’s positive in the left while negative in the right ear. What is the cause? • Left ear - Noise damage • Left ear - Ruptured ear drum • Right ear - Impacted earwax • Right ear - Presbycusis • Left ear – otitis media Causes Sensorineural hearing loss Conductive hearing loss • Presbycusis • Ear wax impaction • Meniere’s disease • Tympanic membrane per. • Noise induced hearing loss • Otitis media w/ effusion • Vestibular schwannoma • Foreign body • Medications • Otosclerosis • Vascular → stroke etc • Cholesteatoma Investigations: • Paget’s disease Facial nerve exam Pure tone audiogram MRI/CT head → acoustic neuroma Ear swab for MC+SPatient is complaining of new onset hearing loss. Which medication was he recently started on? • Ramipril • Furosemide • Atorvastatin • Vancomycin • Lamotrigine• Ramipril There are many but main ones for • Furosemide the exams: 1. Aspirin in large dose (OD) • Atorvastatin • Vancomycin 2. Loop diuretics – furosemide and bumetanide • Lamotrigine 3. Cancer medication • Cisplatin and bleomycin 4. Aminoglycosides • Gentamicin and neomycin30-year-old female presents to the ENT clinic with progressivehearing loss over the past 2 months. She noticed foul smellingear discharge. Otoscopy confirms discharge. Given most likely diagnosis, what investigationshould be request to assess extent of the disease? • Audiogram • CT scan • Venogram • ECG • Otoscopy ENT • Audiogram • CT scan • Venogram • ECG • Otoscopy Conductive hearing loss Cholesteatoma Otosclerosis TM perforation Aetiology Non-cancerous growth of squamous epitheliumand Aetiology Autosomal dominant Aetiology Trauma often pt going for a swim keratin debris within the skull base. Fixation of the stapes at the oval window Infections, direct trauma or barotrauma Young patient 20-40s RF Cleft palate → BIGGESTRISK FACTOR RF Family Hx. Female RF Trauma Symptoms Main → Foul smelling discharge and hearing lossSymptoms Main → Conductive deafness, tinnitus Symptoms Other → vertigo, facial nerve palsy or Main → Conductive deafness anpain cerebellopontine angle syndrome Otoscopy Peroration w/ erythema Otoscopy Attic crust – retraction pocket Otoscopy TM looks normal w/ flamingo tinge caused by hyperaemia. Mx Barotrauma → self limiting → 6-8 Mx Surgical removal weeks → referral to ENT for Mx Hearing aid (amplification) or stapedectomy myringoplasty In patients with chronic or recurrent ear discharge, (reconstruction) Systemically unwell → Abx ensure the attic is visualised to exclude cholesteatomaA 40 year old man complains of 4 month history of hearing loss and vertigo on the right side. O/E the patient has reduced facial expressions with no forehead sparing. Given most likely diagnosis what imaging modality is used to confirm diagnosis? • CT Head • Venography • MRI • USS w/ FNA • Pure tone audiometry Acoustic neuroma is a cause of • CT Head that. • Venography • MRI MRI of the cerebellopontine angle • USS w/ FNA • Pure tone audiometry An 80-year-old man presents to the GP due to struggling to hear call outs (phone) when playing warzone with his friends. He is embarrassed about how often he asks them to repeat themselves. This has been gradually getting worse over the last 2 years. doe Audiometry is shown below. No PMH or known drug What is the most likely ?iagnosis • Otitis externa • Streptomycin prescription • Otosclerosis • Presbycusis • Meniere's disease• Otitis externa • Streptomycin prescription • Otosclerosis • Presbycusis • Meniere's disease Sensory neural hearing loss Vestibular schwannoma Meniere's disease Presbycusis Aetiology Hearing loss occurring with aging. Aetiology Benign tumour of vestibulocochlear nerve Aetiology Sodium channels dysfunction → draws fluid into Degenerativechanges to the inner ear or endolymph → pressure increase cochlear portion of 8 CN. Symptoms Features can be predicted by the affected craniSymptoms Main → vertigo, tinnitus (before vertigo), RF → chronic loud noise exposure. nerves sensorineural hearing loss. Aural fullness • cranial nerve V: absent corneal reflex • cranial nerve VII: facial palsy Symptoms High pitched sounds are difficult to Episodic in nature. Mins to hours. distinguish → speech of other sounds • cranial nerve VIII: hearing loss, vertigo, tiSignss Nystagmus. Positive Romberg mumbled or slurred → heard but not understood Bilateral acoustic neuroma → Neurofibromatosis Mx Acute → prochlorperazine Type 2 Prevention → betahistine / Rehab exercises Audiometry Bilateral – high frequency hearing Imaging MRI cerebellopontine angle impairment. Audiometry is a screening test Driving DVLA need to know – stop driving till symptom control Otoscopy Normal → rule out otosclerosis and Mx Observation. Surgery or radiotherapy. cholesteatoma or foreign body. BPPV lasts Mx Conservative – hearing aids and speech reading. Sudden onset seconds, no deafness unilateral hearing and is exacerbated loss → acoustic neuroma until proven by linear movements. otherwiseA 3-year-old boy presents to the GP with pain behind the right ear. He has a 6-day history of right ear pain / reduced hearing. No discharge. O/E temp 38.8c and HR of 130. Appears to be tugging on his ear. There is swelling around his right ear and the ear appears to be displaced anteriorly. Given the likely diagnosis what is the next step in management? • Safety net advice and review in 1 week • Safety net advice and review in 2 days • Safety net advice + Abx prescription + review in 1 week if not resolving. • ENT admission for assessment • Ask why he has presented by himself?• Safety net advice and review in 1 week • Safety net advice and review in 2 days • Safety net advice + Abx prescription + review in 1 week if not resolving. • ENT admission for assessment -- URGENT • Ask why he has presented by himself?A 26 year old swimmer presents to his GP complaining of itching and redness of his right ear for the past 5 days. He has no trouble with his hearing has noticed some discharge on his pillow. Feels well in himself. On no medication. What is the most likely diagnosis? • Acute otitis media • Cholesteatoma • Otitis externa • Eczema herpeticum • Malignant otitis externa• Acute otitis media • Cholesteatoma • Otitis externa • Eczema herpeticum • Malignant otitis externa Otitis media and otitis externa Otitis externa Acute otitis media (<3 weeks) Malignant otitis externa Pathology Inflammation of external ear canal Relief on pulling pinna – key Otitis externa that has infected the bon ear canal and Acute <3 weeks soft tissue. 90% bacterial Earache, fever, vomiting, followed by Swimming? → pseudomonas aeruginosa purulent otorrhoea if perforation → pain • Diabetics – most common disease relief. • Elderly • Immunocompromised Symptoms Otalgia OM w/ effusion → no signs of acute Single sided ear pain, with increasing purulent discharge that Itching infection or symptoms, just conductive doesnt resolve on previous treatment Otorrhoea hearing loss. • foul-smelling purulent otorrhea Severe pain worse on chewing and at night. Hearing loss Chronic suppurative otitis media — persistent fluid build up and perforation of the tympanic membrane with draining discharge for more than 2 weeks – no ear pain or fever Sign Inflamed or oedematous EAC Loss of light reflex due to building TM CN paralysis (9,10,11) Complication Cellulitis Perforation. Mastoidites, labyrinthitis Progression can lead to osteomyelitis / facial nerve Malignant otitis externa → droop. Management Conservative → keep dry / no cotton Key is to known when to prescribe Abx. IV abx may be needed Medical → • 4> days no improving • Ciprofloxacil (quinelone) to cover for most • Mild discomfort/ Pruritis → Topical • Immunocompromised common organism pseudomonas Acetic acid 2% • <2 years w/ bilateral OM aeruginosa in patients with diabetes • Deafness or discharge → 7 day topical • Perforation Abx +/- steoids Amoxicillin → Erythromycin if allergic If persistent → ENT referral A 30 year old patient presents with dizziness that started 3 days ago. This usually lasts for around 10min. He mentioned that he has had a sore throat 1 weeks ago and denies any trauma to the head of new medication. He feels nauseous and has had no hering disturbance. What is the most likely diagnosis? • Meniere's disease • Benign paroxysmal positional vertigo • Vestibular neuritis • Labyrinthitis • Acoustic neuroma• Meniere's disease • Benign paroxysmal positional vertigo • Vestibular neuritis • Labrinthitis • Acoustic neuroma No such thing as labrinthis, its viral labyrinthitis. Who remembers earthquake tho? V ertigo Meniere's disease • Recurrent episodes lasting 20 minutes to several hour • Sensorineural hearing loss • Tinnitus / feeling ear is full Rotational (room spinning) = vertigo BPPV Side to side (unsteady on feet)= instability • Brief episodes triggered by head movement Vertebrobasilar ischaemia= extension of Faintness • Dix hallpike -> Dix for diagnosis → neck dizziness + history of stroke. nystagmus seen 5Ds • Managed w/ Epley manoeuvre • Dizziness • Dipolopia (occipital cortex) • Dysphagia Vestibular neuritis • Dysartheria (muscle that produce speech) Acute single episode that can last days • Drop attacks (weakness to the quadriceps)Follows viral symptoms • HINTS exam + hearing loss? → labyrinthitis Nystagmus HiNTS exam Vertical / Unidirectional down beating Horizontal or rotatory Red flag- Peripheral central cause like posterior strokeA 75-year-old man presents with dysphagia and halitosis. On the left side of the neck is a small, fluctuant swelling which gurgles when palpated. What is the most likely diagnosis? • Thyroglossalcyst • Pharyngeal pouch • Cystic hygroma • Brachial cyst • Reactive lymphadenopathy Neck lumps • Thyroglossalcyst • Pharyngeal pouch • Cystic hygroma • Brachial cyst • Reactive lymphadenopathy It’s a spot diagnosis game… Thyroglossalcyst Cystic hygroma - lymphatic • Midline often just below hyoid bone • Congenital – question will be about a child • Moves up with protrusion of tongue • Posterior triangle • US: Hypoechoic • Fluid filled lateral Midli ermoid cyst • Hypoechoic • Moves with underlying skin Neck lumps • No movement on tongue protrusion Cervical • Suprahyoid • Thoracic outlet syndrome • Painless muscle wasting of hand US : hyperechoic and heterognous Branchial cyst– embryological Thyroid pathology • Asymptomatic lateral neck lumps to Ranula the anterior sternocleidomastoid • Sublingual gland muscle. • Can be seen inside mouth • Follows infection increasing in size • FNA and USS Pharyngeal pouch Lipoma • Older man • Slow growing • Dysphagia • Soft, fluctuant and not fixed to skin • Regurgitation • Aspiration Quick facts to learn before the exam Epistaxis : Parotid gland 1. Sit forward + pinch nose → works → Naseptin Bell’s palsy (LMN) → pregnant women • Pleomorphicadenomais most 2. Doesn’t work greatest risk group commontumour of the parotid • See bleeding point → Cautery gland (Silver nitrate) → intranasal Urgent referral→ laryngeal cancer epinephrine to prevent re-bleed • 45 with Auricular haematoma • Can’t see →Nasal packing + admit • Persistent unexplained hoarseness • Sameday referralto ENT for I&D to • Unexplained neck lump avoid cauliflower ear Tonsilitis: • CENTOR (Exudate – lymphadenopathy – Quinsy • Abscess fever- no cough) = any 3 or 4 → • Deviation of uvula to unaffected side phenoxymethylpenicillin • Aspiration + drainage + IV abx • Tonsillectomy after 6 weeks Post tonsillectomy haemorrhage? → Hearing loss : assessedby ENT • Sudden onset sensorineural hearing loss Scarletfever → get swab of throat → urgent ENT referral → MRI +/- high ASAP Most salivary stone occur in dose steroids submandibulargland Non- healing TM perforation → myringoplasty(pars tensa closure)Thankyou • Things you can cover in order of importance • Nose bleeds • Parotid pathology • Throat cancer That’s enough copy righting for the day Feedback Form • Insert QR code https://app.medall.org/training/feedback/anonymous?organisation=ace-it&keyword=a538975e6ad391e6d644afcb