AKT questions/ nMRCGP questions

1. A 56-year-old man is seen in the urgent care centre with vomiting and severe left-sided loin pain radiating to his left groin. On examination, his temperature is 37.6°C and he has left-sided loin tenderness. Urinalysis reveals blood+++ and protein++. A diagnosis of renal colic is suspected.In addition to an anti-emetic, which is the single MOST appropriate intervention for this patient? Select ONE option only.

A. Intramuscular codeine phosphate
B. Intramuscular diamorphine
C. Intramuscular diclofenac
D. Intramuscular pethidine
E. Rectal diclofenac

Answer: C

Intramuscular diclofenac 75 mg is the treatment of choice in acute renal colic. An opioid (e.g. pethidine or diamorphine) should be considered if diclofenac is contraindicated or is insufficient to control the pain.An anti-emetic should be administered for nausea and vomiting, particularly if an injectable opioid is given.


2. A 7-year-old boy is brought to the surgery by his father with a 2 week history of headache, rash and intermittent abdominal and joint pains. Urinalysis reveals blood++++ and protein+.What is the SINGLE MOST likely diagnosis in this patient? Select ONE option only.

A. Acute leukaemia
B. Henoch–Schönlein purpura
C. Idiopathic thrombocytopenia
D. Post-streptococcal glomerulonephritis
E. Urinary tract infection

Answer: B

Henoch–-Schönlein purpura (HSP) is a vasculitis which most typically affects young children aged 3 to –8 years old. It is more common in boys. There is usually a preceding infective trigger such as a respiratory tract infection.There may be gastro-intestinal, joint and renal manifestations. There is haematuria and proteinuria in 70%, although this is often asymptomatic. More serious complications are rare. HSP is usually self-limiting and does no’t normally require any specific treatment.There is usually a preceding history of sore throat in post-streptococcal glomerulonephritis, and a rash would not normally be expected.

3. A 53-year-old man attends as a new patient to your practice. He has no previous past medical history and is not taking any regular medication. As part of his new patient check, the following results are obtained:Urinalysis Blood++Mid-stream urine (MSU) NegativeBlood pressure 112/68 mmHgUrea and electrolytes NormalWhich ONE of the following options is the most appropriate INITIAL management for this patient? Select ONE option only. [Show Discussion]

A. Check prostate-specific antigen (PSA)
B. Re-check urinalysis in 2 weeks
C. Referral for renal ultrasound scan
D. Routine referral to renal physician
E. Urgent referral to urological surgeon

Answer: E

Regarding the management of suspected urological cancer:
• Male or female adult patients of any age who present with painless macroscopic haematuria should be referred urgently.
• In male or female patients with symptoms suggestive of a urinary infection who also present with macroscopic haematuria, investigations should be undertaken to diagnose and treat the infection before consideration of referral. If infection is not confirmed the patient should be referred urgently.
• In all adult patients 40 years of age and older who present with recurrent or persistent urinary tract infection associated with haematuria, an urgent referral should be made.
• In patients under 50 years of age with microscopic haematuria, the urine should be tested for proteinuria and serum creatinine levels measured. Those with proteinuria or raised serum creatinine should be referred to a renal physician. If there is no proteinuria and serum creatinine is normal, a non-urgent referral to a urologist should be made.
• In patients 50 years of age and older who are found to have unexplained microscopic haematuria, an urgent referral should be made.Any patient with an abdominal mass identified clinically or on imaging that is thought to be arising from the urinary tract should be referred urgently.