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Dysuria and haematuria are common presentations, but there is no need to get your knickers in a twist over this set of questions!

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Dysuria and haematuria

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Question 1

Stem 1, question 1 of 5

Jana, a 23 year old female, presents to her GP with dysuria, increased urinary frequency and urethral discharge, after a new sexual partner with sporadic condom usage.

What is the most likely diagnosis?
A
Lower urinary tract infection
B
Cystitis
C
Goodpasture's syndrome
D
Urethritis
E
Post-streptococcal glomerulonephritis
Question 1 Explanation: 
The stem highlights a number of risk factors: age, female sex and new sexual partner. Urethritis is usually an STI that presents with dysuria, urethral discharge and/or pruritis at the end of the urethra.
Question 2

Stem 1, question 2 of 5

Neisseria gonorrhoea can cause urethritis, which of the following investigations is first line for detection of this pathogen?
A
Gram stain of urethral discharge
B
Microscopy, sensitivity and culture of urine
C
Renal biopsy
D
Nucleic acid amplification test of urine
E
Polymerase chain reaction
Question 2 Explanation: 
Gonorrhoeal species can be difficult to detect with standard test and so needs nucleic acid amplification testing is the first line as it is the most sensitive method to detect N. gonorrhoea in the urine. Grain staining is often very helpful but can miss 5% of N. gonorrhoea infections.
Question 3

Stem 1, question 3 of 5

12 months later Jana presents to the Emergency Department with sudden onset of colicky pain in her left flank, nausea, vomiting and haematuria.

Given the most likely diagnosis, why is the pain colicky in nature?
A
Stretching of the ureters or collecting system due to increase in intraluminal pressure causes nerve endings to stretch and therefore result in colic pain
B
Compressing of the ureters or collecting ducts due to an increase in interluminal pressure causes nerve endings to stretch and therefore result in colic pain
C
Stretching of the ureters or collecting system due to increase in extraluminal pressure causes nerve endings to fire and therefore result in colic pain
D
Compression of the uterus and bladder due to increased extraluminal pressure causes nerve endings to stretch and therefore result in colic pain
E
Stretching of the ureters or collecting system due to increase in interluminal pressure causes nerve endings to fire and therefore result in colic pain
Question 3 Explanation: 
There are a few steps involved here to get to the answer. Step 1: know the most likely diagnosis...... Renal stones! Step 2: understand how the stones cause a colicky pain (pain that intensifies and gradually reduces in pain). The presence of a stone will cause the ureters and collecting system to stretch due to an increase in INTRA-luminal pressure aka the pressure inside the tube. This causes the nerve endings to temporarily stretch and fire, resulting in pain. As the stone moves, different areas will be under stretch and thus, the pain comes in waves.
Question 4

Stem 1, question 4 of 5

What imaging should be performed to confirm this likely diagnosis?
A
CT urogram
B
Cystoscopy
C
CT abdomen
D
Ultrasound of kidneys, ureters and bladder
E
X-ray of kidneys, ureters and bladder
Question 4 Explanation: 
Renal stones are most commonly composed of calcium and so appear bright white on an X-ray and CT. Remember to always start simply when considering imaging and work up to more invasive or higher doses of radiation such as a cystoscopy or CT scan
Question 5

Stem 1, question 5 of 5

Jana is complaining of plentiful nausea, which of the following is an anti-emetic acting on the D2 receptors only?
A
Alfentanil
B
Cyclizine
C
Domperidone
D
Etoricoxib
E
Olanzapine
Question 5 Explanation: 
Domperidone is a D2 receptor antagonist anti-emetic and so is the correct choice here. Cyclizine is also an anti-emetic but works on H1 receptors. Olanzapine is a selective D2 and 5-HT receptor blocker and can be used for nausea, but is mainly used for it's anti-psychotic effects. Etoricoxib and alfentnil are NSAIDs and strong opioid analgesics respectively.
Question 6

Stem 2, question 1 of 4

78 year old Mustafa presents to his GP with a 2 week history of haematuria and increasing urinary frequency. Mustafa has smoked 15 a day for the last 40 years.

Which of the following diagnoses is likely?
A
Renal stones
B
Goodpasture's syndrome
C
Post-streptococcal glomerulonephritis
D
Trauma
E
Bladder cancer
Question 6 Explanation: 
This history, although short, should be ringing alarm bells as there are some clear red flags. Bladder cancer is strongly linked to age, however the most important causative factor is smoking. The stem highlights an extensive smoking history and so bladder cancer is the most likely compared to the other answer options.
Question 7

Stem 2, question 2 of 4

What examination finding would be expected in someone presenting with bladder cancer?
A
Flank mass
B
New onset left varicocele
C
Lower extremity oedema
D
Unremarkable
E
Hypertension
Question 7 Explanation: 
Examiniations in someone with bladder cancer are usually normal, so sorry for the slight trick question. The other answer options are all examination findings that can occur in renal cancer. Remember that both bladder and renal cancers often present with haematuria and so the examination can be key in differentiating the two diagnoses.
Question 8

Stem 2, question 3 of 4

The GP decides to do some wider reading on causes of haematuria and comes across Goodpasture's syndrome.  What is the key presentation of this syndrome?
A
Dark, reddish brown urine and oedema
B
Haematuria and bony pain
C
Sudden onset of colicky pain and haematuria
D
History of trauma and tenderness to kidney
E
Rapidly progressive renal dysfunction and haemoptysis
Question 8 Explanation: 
Goodpasture's syndrome is a rare disease caused by the presence of autoantibodies to the alpha-3 chain of type IV collage found in the basement membrane of the alveoli and glomeruli. It often presents with simultaneous haemopytsis and renal failure caused by glomerulonephritis. BMJ best practice has a good resource on this topic, but remember there are only 1-2 cases per million!
Question 9

Stem 2, question 4 of 4

A week later a different patient, who is 10 years old, presents to the GP. This patient has new onset haematuria, oedema and reddish brown urine following a sore throat and fever just over a week ago.

What is the most likely diagnosis?
A
Pyelonephritis
B
Cysitis
C
Goodpasture's syndrome
D
Post-streptococcal glomerulonephritis
E
Traumatic injury to the kidney
Question 9 Explanation: 
Post-streptococcal glomerulonephritis is a rare complication following a streptococcal infection which results in an autoimmune reaction. It develops 10 days after the symptoms of strep throat infection and is more common in children than adults.
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