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Haematology , Oncology, Palliative Care, Breast Disease, Renal and UrologyHaematologyAnaemiaApproach to Anaemia: the Mean Cell VolumeQuestion A 24 year oldwoman complains of fatigue and intermittent colicky or travel history. She has not noticed a change in bowel habit and reports a well balanceddiet. Her only medication is the combinedoral contraceptive pill. She is a frequent blooddonor, but was rejectedfromdonation last time, as her haemoglobin was too low. Investigations: Haemoglobin 88 g/L (115-165), MCV 62fl (80-98), WCC 6.8 x 10 /L (4.0-11.0), platelets 423 x 10 /L (150-400), transferrin saturation 10% (15-50), serum iron 6μmol/L (9.0–30.4 ), ferritin 7μg/L (15-300). What is the next most appropriate investigation?Question A 24 year old woman presents to the GP with fatigue, intermittent palpitations andlight-headedness. She has no significant past medical eats a strict vegan diet.cation. On further questioning, she reveals she Investigations: Haemoglobin 83 g/L (115-165), MCV 65fl (80-98), WCC 6.8 x 10 /L (4.0-11.0), platelets 344 x 10 /L (150-400), transferrin saturation 10% (15-50), serum iron 6μmol/L (9.0–30.4 ), ferritin 2μg/L (15-300). She feels strongly about the ethics of her diet, but is open to the idea of medication to improve her symptoms. What is the most appropriate management plan? Iron Deficiency Anaemia (IDA) • Low Iron – Can’t Make Heme – Fewer Hb proteins – Smaller Red Cells • Very common problem, particularly in pre-menopausal women: menorrhagia • Other causes include inadequate iron intake eg. veganism, poor Fe absorbtion eg. coeliac disease, occult blood loss eg. gastrointestinal tumour • Key Investigation is Ferritin • Ferritin stores iron intracellularly – levels drop in iron deficiency as less ferritin is needed • Serum Iron levels are also typically low, whilst transferrin levels are typically elevated • Transferrin expression is upregulated by cells to scavenge all available iron • Yo• Ferritin is also an acute phase reactant – will be falsely elevated Side effects of iron supplements: • Nausea Replace Iron Stores • Abdo discomfort • Diarrhoea/constipation • Ferrous Sulfate 200mg TDS • Black stools • Continue until FBC normalises and for 3/12 after Lifestyle Advice • Encourage iron intake; good sources for vegetarians/vegans IDA include leafy greens like spinach and kale, lentils, beans and chickpeas, tofu and tempeh Management Find the Cause? • Not necessary in menstruating women • Consider TXA/Contraceptives if menorrhagia is bothersome • In other patients, IDA requires investigation for underlying cause • Upper GI Endoscopy and Colonoscopy are Indicated • Coeliac Screen is usefulQuestion A52-year-old femalepresentsto her general practitioner witha two-weekhistoryof lethargyand paraesthesia in her hands. Shedeniesany recent changesin her weight, hasnot had a changein her bowel habitsand denieslowmood or musclecramps. Shetakesno regular medications. Afull blood count revealsthefollowing: Hb 102 g/L (115 - 160) Platelets392 (150 - 400) WBC7.52 (4.0 - 11.0) Haematinicsreveal thefollowing: Folate1.2 ug/L (3-20) Vitamin B12 82 ng/L (197-771) What isthemost appropriateinitial management option?Haematinic Deficiency • Both Vitamin B12 and Folate (Vitamin B9) are important co-factors involved in the maturation of RBC precursors • If either is deficient, RBCs cannot mature properly – anaemia • RBC precursors are larger than RBCs themselves – macrocytosis • Both are diagnosed by simple blood test measuring B12/folate levels • Treatment for both involves replacement: • B12 replaced as hydroxycabalmin, IM injection every few months • Folate replaced orally as folic acid • Treatment of B12 deficiency is important to avoid complications such as peripheral neuropathy and subacute combined degeneration of the spinal cord B12 Deficiency • Pernicious Anaemia: Antibodies to Intrinsic Factor produced; Vitamin B12 must bind IF for absorption • Dietary deficiency, especially strict vegetarians/vegans Causes of • Malabsorption, eg. IBD, Coeliac Disease Folate Deficiency Haematinic •weeks; main sources are green vegetables, nuts anda few Deficiency legumes • Drug Induced: Many drugs interfere with folate metabolism including Methotrexate, Anticonvulsants, Chemotherapy Agents, Trimethoprim • Pregnancy: demand for folate is increased • Malabsorption eg. IBD, Coeliac DiseaseQuestion A 55 year oldwoman complains of 3 months of fatigue and increasing shortness of breath. She was previously well. She has a history of hypothyroidism and takes levothyroxine daily. On examination, you note mildscleral icterus andconjunctival pallor. Her chest is clear. Her heart rate, bloodpressure andtemperature are within normal parameters. Initial bloodtests reveal a markedanaemia with a mildly macrocytic mean cell volume. The rest of her full bloodcount is normal, as is her renal function. Which of the following is the most appropriate diagnostic investigation? Haemolysis • Haemolytic Anaemias typically cause a mild macrocytosis: this is because increased numbers of reticulocytes (immature RBCs) are produced by the marrow to compensate for haemolysis • Reticulocytes slightly larger than normal RBCs • Suspect haemolysis clinically if: • Jaundiced • Unconjugated bilirubin deposited in mucosal tissue • Splenomegaly • Can be a feature due to increased demand on spleen of clearing RBCs • Variety of tests can support haemolysis: • MCV: Mild macrocytosis • Increased levels of unconjugated bilirubin • Increased LDH Levels – released from RBCs when they lyse • Decreased Haptoglobin Levels – this is produced to bind free Hb (otherwise toxic to cells); when excess free Hb is produced then free haptoglobin levels fall • Variety of Causes • G6PD, Hereditary Spherocytosis, AHA, Malaria, Rhesus Disease/ABO Incompatibility in Newborns….Specific Investigations • Blood Film • Can determine some causes, eg. Sickle Cell Disease and Hereditary Spherocytosis/Elliptocytosis, based on RBC Morphology • Diagnose malaria by visualizing Plasmodium parasites • Coomb’s Test (Direct Antibody Test) • Can demonstrate antibodies binding RBCs – key to diagnosing Autoimmune Haemolytic AnaemiaQuestion Regarding blood transfusions, which ofthe following is true?Question An84yearold lady isadmitted for anemergency hip hemiarthroplasty after fallingathomeand sustaininganeckoffemurfracture.Shehasabackground of Alzheimer'sDementia,rheumatoid arthritisand congestivecardiac failureand takesdonezepil,methotrexate,lisinoprilandbisoprolol. Twodaysafter theoperationsheisfound tobeanaemicandundergoesablood transfusion.Uponcompletingthetransfusion,shecomplainsofbreathlessness. HerRRis30,SpO291%onair,HR95withmaintained blood pressure. cracklesonauscultation.Thereispittingoedematomid-calf.ereare bibasal SheisgivenO2therapyviaanon-rebreathermask. Whatisthenextmostappropriatestep inmanagement?Transfusion-Associated Circulatory Overload (T ACO) • Can be easily missed in a sick patient who is often breathless already • Fluid overload leads to pulmonary oedema à usually starts at the end of the transfusion, or after it has finished • Problem is too much fluid given too quickly • Look for signs of fluid overload (raised JVP…) • A small dose of diuretic is sufficient to improve symptoms (eg. IV Furosemide 40-80mg) • Some patients are at particular risk of TACO • Very old and very young • Heart failureent • those at high risk should have transfusion more slowlyTACO à • transfusion-related deathted to SHOT à Most common cause of T ransfusion-Related Acute Lung Injury (TRALI) • Rare • Causes severe breathlessness and hypoxia, typically within 6 hours of transfusion • product bind host WBCs à deposit inod pulmonary vasculature and release cytokines and vasoactive substances pulmonary oedema-cardiogenic • CXR: Bilateral nodular infiltration • May require ventilation, 100% O 2Question An 8year oldboy presents with lethargy andfever. He has been unwell over the last 3weeks with skin boils that only respondto antibiotics for a few days. Investigations: Hb 67(110-160) WCC 0.9(4-11) Platelets 37(150-400) BloodFilm: Blasts with prominent Auer Rods What is the most likely diagnosis?Question A 76 year oldlady presents to her GP with a painless lumpin her inguinal months, and has found herself waking up sweaty at night ona number ofst few occasions. She has a past medical history of osteoporosis and takes alendronic acid. Investigations: Haemoglobin 94(115-160) MCV 82 (78-98) Platelets 155 (150-400) BloodFilm: Smudge Cells seen What is the most likely diagnosis?Acute Leukaemias • ALL: Most common in children; AML: More common in adults, particularly 65-75 but can be any age • chemotherapy: Down’s Syndrome; exposure to radiotherapy or alkylating • Presenting Features: • Anaemia: Tired, SOB, Palpitations, Pale Marrow • Thrombocytopaenia: Purpuric Rash, Prone to Bleeding Failure • Increased frequency of infections • Bony pain and tenderness • Hepatosplenomegaly – Can be a feature of both, but more so ALL • Lymphadenopathy – ALL • Gum Hypertrophy – AML • Thymus Enlargement - can have mediastinal mass effect – ALL • Bone Marrow: >20% Blasts Chronic Myeloid Leukaemia • Most common between 40-60 years old; slight male predominance • Over 80% of cases involve Philadelphia Chromosome translocation • tyrosine kinase)s BCR-ABL Fusion Protein (constitutively active • Presenting Features: • Marrow Failure • Splenomegaly (>75%, often massive) • 30% cases detected by chance • Diagnosis: • Blood Smear: Increased no. granulocytes, monocytes • chromosome presence be sent for cytogentic analysis to confirm Ph • Imatinib: Targeted Therapy Chronic Lymphocytic Leukaemia • Most common type of leukaemia; usually affects older people – 65- 70 most common presentation • Almost always a cancer of B-Lymphocytes – cells are immuno- incompetent • Presenting Features: • Usually insidious – 70% cases diagnoses incidentally on routine FBC • P• CLL can behave a bit like a lymphoma à the B-Cells often go to the lymph nodes • Marrow Failure Symptoms • Can be especially prone to infection due to hypogammaglobulinaemia (lack of antibodies – over 50% of CLL patients) • Fevers, Sweats, Weight Loss • Kind of like the lymphoma ‘B Symptoms’ • Investigations and Diagnosis: • Very markedly elevated WCC • Blood Film: Smudge Cells (Immature white cells break during smear); immunophenotyping • Serum Immunoglobulin Level – Determine degree of immunosuppression • Marrow not usually necessaryQuestion A63-year-old man presentsto hisGP witha 3-monthhistoryof feeling 'tired all thetime' and getting out of month, withlessinterest in pursuing hisusual hobbies. When asked about recent weight loss, althoughhe hasn't weighed himself, hedoesfeel asthoughhiswaist sizehasdecreased ashehasneeded to tighten his belt more, recently. HisGP decidesto arrangesomeroutineblood testswhichshowthefollowing: MCV 88 (77-95)180) Platelets242 (150-400) WBC 4.3 (4-11) ALP 143 u/l (30-100) (55-120) Corrected Ca2+ 3.01 mmol/l (2.2-2.6) Whichfurther investigation ismost useful in investigating thelikely underlying causeof hissymptoms? Multiple Myeloma: CRAB Features • The most common presenting symptom, by far, is bone pain, caused by lytic lesions and pathological fractures • Lower Back Pain is an extremely common site, also rib pain • Can lead to Cauda Equina Syndrome • Hypercalcaemia can result from the increased osteoclast activity within the bone, which results in increased calcium release into the systemic circulation • Renal Failure in multiple myeloma can occur for multiple reasons •produced in the ascending loop of Henle, to form urinary casts, whichycoprotein precipitate in the distal convoluted tubules and collecting ducts, obstructing them, leading to renal failure • Marrow failure can result in anaemia (most commonly), neutropaenia and thrombocytopaenia • Approximately 35% of patients with newly diagnosed Multiple Myeloma have a Hb lower than 90g/L Monoclonal Gammopathy of Undetermined Significance (MGUS) • Paraprotein is present in the blood, but there are no other symptoms • Paraproteinaemia is fairly common with increasing age – 1% over 50, 5% over 80 • Bone marrow may have a mild increase in the number of plasma cells, but it is less than the 10% of all nucleated cells required for myeloma diagnosis • Risk of progression to Multiple Myeloma is 1% per annum • Monitor annually to check paraprotein levelsQuestion A 66-year-oldwoman presents toA&E having hadtwoepisode oftar- like black stools. Her PMH includes chronic gastritis anda mechanical AVR. She is on omeprazole andwarfarin. She appears tobe slightly anxious. What is the most appropriate decision regarding her anticoagulation?Tests of Clotting Pathways • PT = prolonged by warfarin • APTT = prolonged by heparinWarfarin Reversal and Management of High INRQuestion A 76-year-oldman is brought tothe emergency department following a fall. He recently hada hipreplacement andregularly takes atorvastatin, metformin, andapixaban. CT imaging ofthebrain has revealeda subdural haematoma. What antidote shouldbe administered? Anticoagulant Reversal Agent Warfarin Vitamin K/Prothrombin Complex Concentrate Reversal Heparin Protamine Sulfate (More effective for UFH than Agents LMWH) Apixaban, Andexanet Alfa Rivaroxaban Dabigatran IdarucizumabRenalQuestion A52yearold manhasaroutineinsurancemedical.Heiswell.Hehasamedical historynotablefortype1diabetesmellitus,controlled onabasal-bolusinsulin regimen. Hisblood pressureis132/78.Hehasanormalheartrate,respiratory rateand temperature.Hisheartsoundsarepureand hischestclearto ausculation.His calvesaresoftand non-tender. -FullBloodCountNAD • Creatinine145(55-120) • eGFR49(>60) Whatadditionalinvestigationismostappropriateatthispoint?Diabetic Nephropathy • Most common cause of ESRF in Scotland • First clinically detectable sign is microalbuminuria • The albumin is expressed as a ratio with creatinine in order to adjust for the concentration of the urine • Normoalbuminuria: <3mg/mmol • Microalbuminuria: 3-30 mg/mmol • Overt Proteinuria: >30 mg/mmol • Screen for microalbuminuria annually in diabetics alongside renal function (from 5 years post diagnosis in T1DM) • Mx: RAAS inhibition (even if not hypotensive), tight glycaemic control, tight BP control, manage cardiovascular risk factorsGlomerular DiseaseQ A25-year-old malepresentsto hisgeneral practitioner witha 3-day history of haematuria and oliguria, whichdeveloped 2 daysafter suffering from coryzal symptomsand a cough. Hehasno significantpastmedical history. Observationsare: Respiratory rateof 15 /min Pulseof 83/min Temperatureof 37.1ºC Blood pressureof 146/116 mmHg Oxygen saturation of 97% on room air Urinalysisreveals: Protein +, Blood +++ Whichof thefollowing isthemostlikely diagnosis?IgA Nephropathy (Berger’ s Disease) • Most common primary glomerular disease worldwide • Abnormal glycosylation of IgA à Bound by IgG to form immune complexes à Deposition in renal mesangium • Peak presentation in 20s • Can develop during respiratory/GI Tract disease (IgA production +++) • IgA: During/Shortly After; Post-Strep: 10-14 days after • Always haematuria, variable proteinuria • Can be hypertensive/renal impairment/both • Definitive diagnosis: renal biopsy • Mx: ACEi, corticosteroids in rapidly progressive disease only • 20% progress to ESRFQ A62-year-old woman isadmitted to thehospital withsymptomsof fluid overload. Shehaspitting oedema up to her mid-thigh, whichhasdeveloped over thecourseof a week. Sheisotherwise asymptomatic. review by thehepatology team for a recentdiagnosisof HepatitisB. Her medicationsincludeunder methadone. abnormalitiesarenoted. Ablood testisdoneand theresultsarebelow.stick, butno other Na+ 136 (135-145) K+ 2.7 (3.5-5.0) Urea 9 (2-7)3 (22-29) Creatinine300 (55-120) Albumin 28 (34-54) Whatisthemostlikely diagnosis?Membranous Nephropathy • Commonest cause of nephrotic syndrome in adults • Autoantibodies (IgG) against antigens on podocyte cell surface (eg. Phospholipase A )2 • 90% Idiopathic, 10% in response to known trigger: • Malignancy – prostate, lung, lymphoma, leukaemia • Infections - Hepatitis B, syphilis • Drugs – Now rare – gold, penicillamine • Presentation is usually with nephrotic syndrome +/- hypertension, renal impairment • Mx: ACEi, consider cyclophosphamide/rituximab if severe Immunofluorescence: IgG • Rule of 1/3s for prognosis: better, persistent nephrotic autthe podocytes and GBMetween syndrome, ESRFQ been having intermittent fevers, andhas a3week history ofan She has erythematous, urticarial-type rash affecting her abdomen andlower limbs. Her past medicalhistory is notablefor a recent GORD diagnosis, hypothyroidism andfibroids. She is taking levothyroxine andomeprazole. Her bloodresults reveal a peripheralbloodeosinophilia and a creatinine of300. There are trace amounts ofprotein andbloodon a urine dipstick. What is the most likely diagnosis?Acute Interstitial Nephritis • Characterised by acute inflammation affecting the tubulointerstitium (bulk of the kidney) • Presents with AKI/evidence of renal impairment • About 30% will have an eosinophilia • About 10% have an ‘allergic triad’ of fever, rash and arthralgia • Causes remembered by ‘AIN’: • Allergic: Antibiotics, Omeprazole, NSAIDs. Drugs most common cause • Infective: Any bacteria causing pyelonephritis • Noxious (Toxins): Mushrooms/Plant toxins • Renal biopsy for diagnosis; treat underlying cause 1 3 2 Davidson’s 22ed p497 3 2 Davidson’s 22ed p497 3 Davidson’s 22ed p497Davidson’s 22ed p497Q feeling acutely unwell, complaining ofmuscle weakness, nausea and vomiting. His past medical history is significant for end-stage renal failure due todiabetic nephropathy. He has an arteriovenous fistula andattends thrice weekly haemodialysis sessions. However, he missedhis last session. Investigations: K+7.5(3.5-5) gentleman's presentation?changes wouldnot be in keeping with thisQ The ECGreveals tall, tentedT waves. Which ofthe following is the immediate management priority?Hyperkalaemia Immediate priority: Stabilise the myocardium • Calcium Gluconate is given peripherally – 10ml 10% calcium gluconate • May need to be repeated 2-3 times • Does nothing to actually lower the potassium • Calcium Chloride: alternative if central access Hyperkalaemia Short Term Medical Management: Management • Insulin-Dextrose Infusion • Can lower K by about 1mmol/L within 15-30 minutes • Beware Iatrogenic Hypoglycaemia – monitor BMs • 10 units soluble insulin in 25g glucose • Salbutamol Nebuliser (10-20mg) • Aim to restore renal function (?IV Fluids) • May need haemodialysis if refractory to other treatmentsQ A 72-year-oldlady is admittedtothe orthopaedic wardwith a Weber C ankle fracture awaiting an ORIF. She is NBM. She has a PMH of hypertension andtakes atenolol andbendroflumethiazide. She is 50kg. T 36.0, HR80, BP 135/75. Her JVP is 2-3cm, lungs clear, nopitting oedema. Na 132, K 5.6, Urea 4, creatinine 82 After a performing a fluidbalance assessment on this patient what kindoffluidreplacement does sheneed?Q A 72-year-oldlady is admittedtothe orthopaedic wardwith a Weber C ankle fracture awaiting an ORIF. She is NBM. She has a PMH of hypertension andtakes atenolol andamlodipine. She is 50kg. T 36.0, HR80, BP 135/75. Her JVP is 2-3cm, lungs clear, nopitting oedema. Na 137, K 5.6, Urea 4, creatinine 100 How much fluiddoes she needover a 24hr period?Q T 36.0, HR80, BP 135/75. Her JVP is 2-3cm, lungs clear, nopitting oedema. Na 137, K 5.6, Urea 4, creatinine 100 Which ofthe following is the most appropriate maintenance fluidfor this patient?Q A 50-year-oldman presents toA&E with a 3week history ofarthralgia andmyalgia. He has been passing dark urinefor thelast 3days andis SOB with pitting oedema tohis knees andis complaining of palpitations andgeneral fatigue. He takes noregular medications. BP 150/95. Hb 130, K+7.5, Urea 28, Creatinine 650. Urinalysis: Blood ++++, protein +++. Q: Which ofthe following is most likely?Q A 50-year-oldman presents toA&E with a 3week history ofarthlagia andmyalgia. He has been passing dark urinefor thelast 3days andis SOB with pitting oedema tohis knees andis complaining of palpitations andgeneral fatigue. He takes noregular medications. BP 150/95. Hb 130, K+7.5, Urea 28, Creatinine 650. Urinalysis: Blood ++++, protein +++. Q2: Which ofthe following is the most likely underlying disease?Q A patient attends routine renal clinic for assessment oftheir known CKD stage 4. Q: Which ofthe following eGFRmeasurements are you most likely to see in this patient?Q Q:Which ofthe following are NOT involvedin the management of CKD?Oncology and BreastQ A 78year oldman presents with immobility, diffuse abdominal pain, bilateral leg weakness andanuria. He has a history ofangina and bronchial carcinoma. Catheter drains 600ml. A digital rectal exam is normal. Which investigation is most likely togive the diagnosis?Q Imaging confirms compression ofthe spinal cordby bony metastasis What is the most appropriate immediate management ofthis patient?Malignant Cord Compression • Back pain, retention/incontinence, weakness, saddle anaesthesia, sensory changes • Investigations • MRI whole spine within 24 hours • If first presentation of Ca – CT, PSA, myeloma screen, AF, HCG (if young male) • If known mets – restaging CT • Management • Analgesia • Dexamethasone 16mg (before MRI) • Surgical decompression or radiotherapy or chemoQ A 24year oldgentleman presents tothecancer assessment unit feeling generally unwell. He woke upin a coldsweat last night and feels shivery this morning. He has Hodgkin's Lymphoma andreceived his secondroundofchemotherapy 3days ago. On examination he is febrile to39.5C, his heart rate is 85andhis bloodpressure is 122/71. His respiratory rate is 18. His heart sounds are pure andhis chest is clear. His abdomen is soft. What is the most appropriate management at this stage?Neutropaenic Sepsis • Temp >38 or signs/symptoms of sepsis in a person with a neutrophil count of <0.5 x 10 9 • Immediate management • Sepsis 6 • Extensive septic screen incl swabs, CXR, cultures • Broad spec Abx – Tazocin & Gentamicin • Consider Filgrastim – Boosts neutrophil production • Rationalise antibiotics with results from screen • If no improvement 48 hours after Abx: • Reculture and reassess • Consider empirical change to Abx e.g. Meropenem, vancomycin • If still no response at 96 hours: • Look for fungal disease; Consider empirical antifungal e.g. amphotericin B • Consider CT chest/abdomenQ You are the FY2andhave just startedyour night shift. You are called tosee an 89-year-oldman with metastatic prostate cancer whohas an uncorrectedcalcium of2.9mmol/L . On his bloods you alsonote he has an albumin of28g/L (low). The range for correctedcalcium is 2.2to2.6mmol/L. Q: What is the most appropriate initial course ofaction?Q A 67-year-oldretirednurse present tothe GP with a large lumpabove her right nipple. She has nosystemic symptoms andO/E there are no nipple changes. She is referredtobreast clinic for triple assessment. US +mammography show a suspicious lesion, nonode involvement, coreBx : grade 3invasive duct carcinoma NST ER+ve HER–ve. Staging T1N0M0. Q: Which ofthe following medications may be helpful in this patient at this stage?Q You are the FY2working on the oncology ward. You are askedby your registrar tocounsel a woman recently diagnosedwith HER2+Breast cancer about trastuzamab (Herceptin), which she is due to commence shortly. What investigation shouldyou advise this woman that she will require before, andat regular intervals whilst taking this medication?UrologyQ A 38-year-oldman presents tosurgery due toa 3month history of scrotal swelling anddiscomfort. On examination, there is unilateral swelling in the left scrotum which transilluminates brilliantly. The swelling is soft andnon-tender. Due tothe presence offluid, the testis is not fully palpable. What is the most likely diagnosis? Testicular Pathology C • Q: What are the following diagnoses? A B Testicular Pathology C • Q: What are the following diagnoses? A B Idiopathic scrotal oedema (ISO) Testicular Pathology • Q: What are the following diagnoses? C A B Idiopathic scrotalTesticular torsion oedema (ISO) Testicular Pathology • Q: What are the following diagnoses? C A B Varicocele Idiopathic scrotalTesticular torsion oedema (ISO)Q A 21-year old man presents tohis GP with a hardswelling in his left scrotum. On examination the GP finds it cannot be separatedfrom the testis. Which ofthe following shouldbe includedin the bloodtests the GP orders?Q A 32-year-oldman presents with severe left acute loin pain. He also complains ofnausea andvomiting andis apyrexial. CT shows an obstructed25mm stone locatedin lower calyx ofthe left kidney. Q: Ofthe following, which is the most appropriate management for this patient?Q Which ofthe following is NOT an indication for urgent intervention of nephrolithiasis?Q A 53year oldman is experiencing recurrent kidney stones. He hasa past history ofdiabetes, IHD, hypertension, open-angle glaucoma, andgout. He has alsobeen taking vitamin D for a diagnosis of seasonal-affective disorder. Which ofhis medications is least likely tobe causative?Nephrolithiasis • <5mm – watch and wait • <10mm – can offer medical mx e.g. tamsulosin, CCBs • >10mm (or anuria, infection AKI, refractory pain or N&V) – consider SWL, ureteroscopic lithotripsyQ A 68-year-oldman is referredtothe urologists with LUTS andan enlarged, irregular prostate on DRE anda raisedPSA. A transrectalUS andBx is performedandpathology reports Gleason score 4+4. Spinal metastases are seen on CT, though he has not hadany symptoms from this. Q: Which ofthe following wouldbe the most suitable first line treatment?Q A 72-year-oldman undergoes a CT for investigation ofsuspected diverticulitis. The radiology report identifies an incidental nodule on the lower pole ofthe left kidney. This is later confirmedas a renal cell carcinoma. Q: Which ofthe following is NOT a recognisedfeature ofrenal cell carcinoma?Q This man was treatedfor his RCC with laparoscopic nephrectomy and has made a goodrecovery. Recently, he has alsohadresection ofhis cataracts, but unforunatelyduring the procedure he was discovered tohave a lesion ofhis retina later confirmedas retinal hemangioblastoma. What condition is likely tobe causing this?Good luck!