Ophthalmology, Urology & Sexual Health

A 65-year-old woman has a sudden painful red eye with blurred vision, nausea and a fixed, mid-dilated pupil. She sees haloes around lights. What is the diagnosis?

• AA corneal abrasion — pad the eye and review in a week
• BAcute angle-closure glaucoma — an emergency requiring immediate ophthalmology referral✓
• CConjunctivitis — treat with chloramphenicol drops
• DAnterior uveitis — start topical steroid drops in primary care and review in a week if the pain and blurring have not settled

Answer: Severe pain, haloes, a hard eye and a fixed mid-dilated pupil are the hallmarks of acute angle-closure glaucoma, which threatens sight within hours; the patient needs same-day specialist treatment to lower the intraocular pressure.

A 70-year-old man reports gradual painless loss of central vision and distortion of straight lines. What is the most likely diagnosis?

• ABacterial conjunctivitis of both eyes
• BAcute angle-closure glaucoma of the left eye
• CRetinal detachment involving the macula
• DAge-related macular degeneration✓

Answer: Gradual central visual loss with metamorphopsia (straight lines appearing wavy) is typical of macular degeneration. Retinal detachment causes flashes, floaters and a curtain across the vision, and glaucoma is painful when acute.

A 25-year-old contact-lens wearer has a painful red eye with photophobia and a watery discharge. What is the most important action?

• AAdvise an over-the-counter antihistamine
• BSame-day referral to ophthalmology to exclude microbial keratitis✓
• CReassure and advise a break from lenses for a day, with lubricating drops if the eye stays sore
• DPrescribe chloramphenicol drops four times a day and review in a week if it has not settled

Answer: A painful red eye in a contact-lens wearer is keratitis until proven otherwise, and Pseudomonas keratitis can perforate the cornea within days. Same-day slit-lamp examination and cultures are needed.

A 68-year-old man reports hesitancy, a poor stream and nocturia. His prostate is smoothly enlarged and PSA is normal. What is the first-line drug treatment for bothersome symptoms?

• AImmediate referral for prostatectomy
• BAn antibiotic course for prostatitis
• CAn alpha-blocker such as tamsulosin✓
• DA loop diuretic at night

Answer: Benign prostatic enlargement with bothersome lower urinary tract symptoms is treated first with an alpha-blocker, which relaxes smooth muscle in the prostate and bladder neck; a 5-alpha-reductase inhibitor is added for larger prostates. A diuretic would worsen nocturia.

A 15-year-old boy has sudden severe pain in one testicle with vomiting, and the testicle lies high and horizontal. What should happen?

• AImmediate surgical exploration, since testicular torsion must be relieved within about six hours✓
• BAn ultrasound scan the following day, since imaging is needed to confirm torsion before any operation is considered
• CA course of antibiotics for epididymitis, which is far commoner than torsion in adolescents
• DAnalgesia and review in the outpatient clinic within a week

Answer: Torsion is a surgical emergency: the testicle becomes non-viable after roughly six hours of ischaemia. Sudden severe pain in an adolescent with a high-riding testicle is explored without waiting for imaging.

A 22-year-old woman has vaginal discharge; on examination there is no abdominal, adnexal or cervical motion tenderness. Testing confirms uncomplicated Chlamydia trachomatis infection. What is the first-line treatment?

• AMetronidazole 400 mg three times daily for seven days, with no need to test for other infections
• BNo treatment, since chlamydia clears on its own within a few weeks in most young women
• CDoxycycline 100 mg twice daily for seven days, with partner notification and a test for other sexually transmitted infections✓
• DA single dose of azithromycin 1 g with no follow-up, which remains the first-line treatment because a single dose guarantees adherence

Answer: UK guidance recommends doxycycline for seven days as first line for uncomplicated chlamydia (azithromycin is now second line), with partner notification and full sexual health screening. Untreated infection causes pelvic inflammatory disease and infertility. Pelvic inflammatory disease itself needs a different 14-day regimen (intramuscular ceftriaxone, then doxycycline with metronidazole).

A 30-year-old man asks for emergency HIV post-exposure prophylaxis after a high-risk exposure 24 hours ago. What advice is correct?

• APEP is only effective if started within one hour of the exposure, so it is now too late to be of any benefit
• BPEP is taken as a single dose, so a second visit is not needed
• CPEP is not available in the UK outside hospital and can only be started by an infectious diseases consultant
• DPEP should be started as soon as possible and within 72 hours of the exposure, for 28 days✓

Answer: Post-exposure prophylaxis is a 28-day course of antiretrovirals that must start within 72 hours of exposure, the sooner the better; it is available through sexual health clinics and emergency departments.

A 35-year-old woman with a urinary tract infection is otherwise well and not pregnant. What is the recommended treatment?

• AAmoxicillin for ten days, with a repeat urine culture at the end
• BIntravenous gentamicin as a single dose in the emergency department
• CNitrofurantoin or trimethoprim for three days✓
• DNo antibiotic, since uncomplicated UTIs are usually viral and self-limiting

Answer: NICE recommends a three-day course of nitrofurantoin (if eGFR is adequate) or trimethoprim for uncomplicated lower UTI in non-pregnant women. Amoxicillin has high resistance rates, and intravenous treatment is for pyelonephritis or sepsis.