Clinical Flashcards
Macro and micro vascular complications of diabetes?
Macro vascular:
Heart attack, angina
Stroke
Peripheral vascular disease
Micro vascular:
Retinopathy
Diabetic nephrology
Neuropathy
Cardiovascular risk history points
CHOKLEDDS
Coronaries
Hypertension
Obesity
Kidneys
Lipids
Exercise
Diabetes
Diet
Smoking
Decompensated liver disease signs
JEAVS C
Jaundice
Encephalopathy
Ascites
Variceal bleeds
SBP
Coagulopathy
Signs of portal hypertension
S CARS
Splenomegaly
Caput Medusa
Ascites
Rectal/oesophageal varices
Spider naevi
Differential list for:
Pansystolic murmur
Mitral regurgitation
Tricuspid regurgitation
VSD
HOCM (though usually ESM)
Differential list for:
Ejection systolic murmur
Aortic stenosis
Aortic sclerosis
HOCM
ASD
Pulmonary stenosis
Mitral regurgitation signs of severity
PLEDS S123
Pulmonary hypertension
Left heart failure
Early diastolic rumble (due to increased flow in diastole)
Displaced volume loaded apex beat
Small pulse volume (very severe)
Soft S1
Split S2
S3
Aortic stenosis signs of severity
SLAPS
Slow rising, low volume carotid pulse
Left heart failure
Aortic thrill
Paradoxical splitting of S2
S4
Echo criteria for severe aortic stenosis
Mean gradient: >40
Vmax >4
Aortic valve area <1
Acromegaly features
Hands:
Large
Thick skin
Median nerve entrapment/Carpal tunnel
Hyperhydrosis
Feet:
Wide
Thick heel pad
Upper limb:
Proximal myopathy
Axilliary skin tags
Blood pressure
Face:
Visual fields with pin
Fundoscopy
Macroglossia
Frontal bossing
Enlarged mandible
Teeth splaying
Acne
Hirsutism
Chest:
Gynaecomastia
Galactorrhoea
Heart
Abdomen:
Organomegaly
Testicular atrophy
Lower limbs:
Osteoarthritis
Pseudogout
Ask for urine looking for glycosuria
Acromegaly features
Hands:
Large
Thick skin
Median nerve entrapment/Carpal tunnel
Hyperhydrosis
Feet:
Wide
Thick heel pad
Upper limb:
Proximal myopathy
Axilliary skin tags
Blood pressure
Face:
Visual fields with pin
Fundoscopy
Macroglossia
Frontal bossing
Enlarged mandible
Teeth splaying
Acne
Hirsutism
Chest:
Gynaecomastia
Galactorrhoea
Heart
Abdomen:
Organomegaly
Testicular atrophy
Lower limbs:
Osteoarthritis
Pseudogout
Ask for urine looking for glycosuria
Causes of isolated Splenomegaly?
HAEM RIP
Haematological
Infection: CMV EBV
Portal hypertension with cirrhotic liver
Rheum: feltys syndrome
Causes of isolated Splenomegaly?
HAEM RIP
Haematological
Rheum: feltys syndrome
Infection: CMV EBV
Portal hypertension with cirrhotic liver
Haem exam: where to next
Inguinal nodes
Hands
Elbow nodes
Face: eyes and mouth
Neck nodes
Spine
Shoulder bones
Hips bones
Legs
Long case history screen
(MOCCHHASS)
Mental health
OSA
CKD
Chronic pain
Haem (clots/bleeding/anaemia)
Heart
Attacks
Strokes
Surgeries
SHX
A-J
Accomodation
ADLs
Business
Coping?
Drives?
Every day is like…
Finances
GP
Home help
Insight
Judgement
What does calcitriol indicate on a drug chart in CKD?
Secondary hyperparathyroidism
Differential list:
- peripheral sensory neuropathy with reduced vibration and pinprick sense
- absent reflexes
- unsteady gait with Romberg positive
Peripheral sensory neuropathy without motor component:
Insults:
- Diabetes
- EtOH
- B12
- Chemo
Immune:
- Sensory variant CIDP
- Paraneoplastic
Hereditary:
- CMT
Peripheral sensorimotor neuropathy
Absent reflexes
Dorsal columns affected, anterior spared
CIDP
Paraneoplastic
Diabetes
EtOH
B12
Hereditary eg CMT
Upper motor neuron pyramidal weakness
Spastic gait
Hyperreflexia
Hereditary spastic paraparesis
Cerebral Palsy
Cervical myelopathy
Bilateral lacunar infarcts
Ataxia
Nystagmus
Normal reflexes
Peripheral sensory neuropathy
INSULTS EtOH
IMMUNE Paraneoplastic
HEREDITARY SCA
Dual pathology
Distal myopathy or LMN weakness
Myotonic dystrophy
Critical illness myopathy
Inclusion body myositis
MND LMN variant
Macroalbuminuria:
Urine ACR over?
24h urine albumin?
Urine PCR over?
24hr urine protein?
Urine ACR
Men >25
Women > 35
24 hr albumin >300
Urine PCR
Men >40
Women > 60
24hr protein > 500
Microalbuminuria
ACR cut off
PCR
Albumin
Protein
ACR:
Men 2.5-25
Women 3.5-25
PCR:
Men 4-40
Women 6-60
Albumin
30-300
24h protein
50-500
Anaemia of CKD targets
Hb 100-115
Ferritin >200
Transferrin saturation >20%
Manage hyper PTH or chronic inflammation
Management of renal bone disease and targets?
Manage hyperparathyroidism:
Target 2-9x ULN
Calcitriol for secondary hyperparathyroidism
Vitamin D replacement (only if calcium and phosphate within targets)
Cinacalcet in dialysis pts
Parathyroidectomy for tertiary hyperparathyroidism
Manage phosphate:
Target to high end of normal range
Phosphate binders with meals
Low phosphate diet
Keep in mind often get osteomalacia, DEXA not helpful as architectural problem rather than density problem
When to treat lipids in CKD?
Age >50 with any stage CKD should have statin
Add ezetimibe below eGFR 60
Age < 50, statin if other risk factor (eg. Coronary disease)
Management renal acidosis?
Aim bicarb in low 20s
Can give sodibic
Keep in mind salt load can worsen fluid overload
Indications for dialysis
Acidosis
Electrolytes
Intoxication (drug build up)
Overload
Ureaemia
Management hyperkalaemia in CKD
Stop offending agents:
Spiro
ACE
Lifestyle:
Low K diet
Drugs:
SGLT2 or thiazide
Resonium
Dialysis
Management of OSA
Weight loss
Avoid CNS depressants eg alcohol
CPAP
Management restless legs
Iron replacement and replace if deficient
Non pharm therapies
Warm/cool compress
Dopaminergic agents (eg pramipexole)
COPDX
Confirm diagnosis
Optimise function
- non pharm: pulm rehab
- pharm: stepwise inhaler introduction
Prevent deterioration
- cease smoking, vaccines, mucolytics
Develop plan of care
- action plans, ACD
Manage exacerbations
- steroids
- inhaled bronchodilators
- antibiotics
- oxygen
- NIV for T2RF
Foot drop:
Dorsiflexion weak
Eversion weak
All else in tact
Peroneal nerve
Foot drop:
Inversion weak
Eversion weak
Dorsiflexion weak
Hip abduction weak
Internal rotation hip weak
L5
Foot drop:
Sciatic nerve
Inversion weak
Eversion weak
Dorsiflexion weak
Plantar flexion weak
Knee flexion weak
Ankle jerk absent
Causes of upper lobe fibrosis?
SCHAART
Sarcoidosis, silicosis
CF
Histiocytosis
Ankylosis spondylitis
Allergic bronchopulmonary aspergillosis
Radiation
Tuberculosis
Transplant issues
Immunosuppression side effects:
- infection
- malignancy
- drug specifics
Graft function
Rejection (need surveillance)
Psychosocial
Massive hepatomegaly
Cm cut off?
Differentials?
> 20cm
Myelofibrosis
Myelodysplasia
Cancer: Mets or hepatoma
Chronic liver disease with fatty infiltration
TR/severe RHF
Moderate hepatomegaly
Cm cut off?
Differentials?
15-20cm
Haemochromatosis
CML
Lymphoma
Fatty liver disease
As for massive
Mild hepatomegaly
Cm cut off
Differentials
12-15cm
NAFLD
Haematological causes:
CLL, myelofibrosis
Chronic liver disease early stages
Massive Splenomegaly
CM cut off
Differentials
> 7cm
Myelofibrosis
CML
Myelodysplasia
Moderate splenomegaly
Cm cut off
Differentials
3-7cm
Lymphoma
CLL
Polycythaemia rubra Vera
Portal hypertension
Difference between NYHA III and IV
III comfortable at rest
IV not comfortable at rest
Difference NYHA II and III
II = Slight limitation, symptoms with ordinary activity
III = marked limitation, symptoms with less than ordinary activity
Difference between NYHA class I and II
Class I no symptoms
Class II symptoms with ordinary activity
