General Medicine Flashcards
DRILL = Falls history
- Frequency and general mechanisms
- RFs
○ Intrinsic:
§ Mobility issues (MSK / neuro)
§ Polypharmacy
§ Pain / fatigue / weakness
§ Poor vision
§ Cardiac issues / syncope
§ Autonomic neuropathy
§ Seizures
§ ETOH / drug use
○ Extrinsic
§ Environmental clutter
§ Many steps - Complications / injuries
○ Bone health / fractures
○ Anticoagulation - Management / Falls Prevention
○ Mx of RFs
○ Gait aids / visual aids
○ Footwear
○ Balance training
○ Home Ax
- RFs
How will you manage this person’s fall’s risk?
- The risk of falls is high in this individual and multifactorial
- I would address their risk factors in order to prevent future falls and involve the patient in this decision-making:
○ Re: Polypharmacy I would perform a thorough medication review and consider ceasing ____
○ Re: mobility issues, I would refer for an exercise program which focuses on balance and strengthening; and organise a home Ax for hazard identification
○ I am aware that Vit D has some evidence for falls prevention and I would ensure they were replete - I would also aim to reduce their risk of a serious complication from their fall by
○ Ix and Mx osteoporosis
○ Carefully considering their anticoagulation
○ Organising a falls alarm if no one is home with them
I would then monitor our interventions with regular follow up
- I would address their risk factors in order to prevent future falls and involve the patient in this decision-making:
How would you investigate this person’s headaches?
DDx - tension / migrainous (character) - infections (meningeal / intra-cerebral) - haemorrhage - space-occupying lesions Ex - papilloedema - neurological disturbance Ix - CTB - LP
How would you assist this person to quit smoking?
• I would firstly assess their readiness and encourage them that it is never too late to quit
• I would also emphasis the benefits of quitting on their health, but also financially
• If they were ready, then I would use a combination of pharmacological and non-pharmacological measures
○ Non-pharm ->
§ refer to QUITLINE for counselling and support
§ Enlist the support of family and friends
○ Pharm ->
§ NRT
§ Other agents include Bupropion and varenicline, but both of these pose risks in patients with epilepsy and active mental health conditions
- Regular follow up will be vital to support them to maintain their abstinence from smoking
How would you manage this person’s chronic pain?
Chronic pain is an incredibly complex issue to manage. I would utilise a multidisciplinary approach and focus on the non-pharmacological strategies which will be the pillar of management.
- I would explore the diagnosis of chronic pain syndrome and exclude reversible contributors that may be causing ongoing damage to tissues (inflammation / degeneration etc)
- I would prioritise building a good therapeutic relationship with the patientand begin process of education about the nature of chronic pain and set realistic expectations and work on the shared goal of optimising function and quality of life
- In terms of management, there is a wide breadth of non pharmacological strategies we could try. This involves engagement in a multidisciplinary chronic pain clinic with variety of allied health specialists including PT, OT, psychologists, and group services.
- Physical therapy with massage, yoga, or hydrotherapy
- Psychology input for cognitive-behavioural strategies and meditation techniques
- Occupational therapyto explore any aids and task simplification to maximise functionality
- Consideration of support groups
In terms of pharmacological options, in chronic pain, our options are limited, and they are only an adjunct to allow the patient to participate in non-pharmacological strategies
How will you assess frailty?
Frailty is a phenotype which relates to - Weight loss - Slow gait - Weakness / weak grip strength - Lethargy - Sedentary lifestyle There are a number of risk factors: - Chronic inflammation and medical co-mordibities - Smoking / ETOH - Poor nutrition
This frailty and associated sarcopenia puts this person at increased risk of falls
How will you address this person’s frailty?
- I would address this person’s frailty through a number of measures
- The cornerstone is increasing exercise to as much as is tolerated, with even very low amounts showing benefit in this population. Resistance training is optimal
- I would also encourage other aspects of a healthy lifestyle, with avoidance of smoking and ETOH, and adequate nutrition
As frailty is closely linked to increased Falls risk, I would also be optimising their relevant risk factors for falls prevention
How will you work up this person’s fatigue?
DDx:
- Acute/Chronic medical disorders
- > chronic inflam conditions
- > malignancy
- Psychological conditions
- > Depression / Trauma
- Medications
- > opioids
- > benzos
- > antipsychotics
- Lifestyle
- > Substance use
- > Poor nutrition
- > Poor sleep
How will you work up this person’s SOB?
In this person my main differentials with regards to key contributors are: • Cardiac ○ Heart failure ○ IHD ○ Valvular pathologies such as aortic stenosis ○ Arrhythmias such as AF • Respiratory ○ Obstructive lung diseases ○ ILD ○ Effusions (infective / malignant / transudative) ○ Pulmonary HTN ○ PE ○ Masses ○ Chronic lung infection • Metabolic ○ Obesity + resultant deconditioning ○ Anaemia ○ Metabolic acidosis in CKD I would evaluate this with some further Ix: - Bedside -> ECG, pulse oximetry - Pathology ○ FBE, UEC, BNP - Imaging: ○ CXR ○ If high suspicion of parenchymal lung disease -> CT +/- PA ○ TTE, perhaps stress if concerned about CAD - Special tests ○ PFTs pre/post bronchodilator
DRILL = ETOH use history
- Duration
- RFs:
○ Depression
○ FHx - Severity
○ How much in the day
○ What type of ETOH
○ When they start drinking - Management
○ Previous attempts to cease - Complications
○ Accidents
○ Liver
○ Cardiac
○ Cognitive / Neuro - Psychosocial
○ Impacts on work / relationships
○ Insight
- RFs:
How would you assist this patient to achieve ETOH abstinence?
This is a complex issue which does require a good therapeutic relationship and a long-term approach to behavioural change
- Currently this person is ___ stage of behaviour change
- I would approach this in a multi-modal manner
○ As a person who is dependant on ETOH, they will need to detox and undergo a safe withdrawal. This should occur in the inpatient setting as they are at high risk of seizures
○ Then I would institute non-pharmacological strategies of counselling and connection with group therapy to support abstinence, through AA group or similar
○ I would consider pharmacological supportive management
§ Thiamine supplementation
§ Acamprosate (if liver disease)
§ Naltrexone (not in liver disease)
Vital to success will be close monitoring and follow up to continually encourage ETOH abstinence
DRILL = Chronic pain history
- Pain history ○ Type / duration / location ○ Triggers / relieving factors ○ Severity over time - IMPACT - RFs ○ Mental health co-morbidities ○ MSK / inflam conditions ○ Substance use - Management to date ○ Non-pharm ○ Pharm - Complications of management - Monitoring
How will you manage this person’s depression?
This person’s depression is heavily impacting their enjoyment of life and their ability to engage in care of their other medical conditions
Firstly I would like to confirm the diagnosis and exclude other contributors:
- TFTs
- Nutritional deficiencies / anaemia
- FBE/ UEC / LFT
- Brain imaging
Once diagnosis confirmed ->
- To manage this, I would firstly prioritise establishment of an effective therapeutic relationship through follow up appointments, and ensure their loved ones are as involved as possible
- Then this will require a multi-modal approach
○ I would address any modifiable risk factors such as current social isolation / financial stressors / troubling symptoms of chronic disease
○ In this person, non-pharmacological strategies may be very effective and are the safest first option. I would refer for a MHCP to access multiple psychology sessions for some simple techniques and psychotherapy
○ Upon reassessment if there were ongoing symptoms I would consider introducing Pharmacotherapy. My first options are usually escitalopram 10-20mg or Sertraline 50-200mg, which are well tolerated in the general medical population
○ I would consider if chronic pain is co-existent -> duloxetine 60-120mg
○ If sleep and weight loss are issues -> Mirtazepine 15-30mg
- I would ensure regular follow up to monitor for adverse effects of his therapy and monitor progress
DRILL = Depression History
- Diagnosis / duration
- Symptoms
○ Mood
○ Anhedonia
○ Sleep
○ Weight / appetite
○ Guilt / low self worth
○ Hopelessness
○ Suicidality- Contributors
○ Pain
○ Chronic illness
○ Social circumstances
○ Substances (steroid / ETOH) - IMPACT
○ Relationships
○ Self care / adherence
○ Engagement in community - Management
○ Psychological
○ Pharmacotherapy - Protective factors
○ Social support / family
○ Sense of purpose
○ Spirituality
- Contributors
How will you manage this person’s fatigue?
I would start by addressing any modifiable contributor and ruling out other likely underlying aetiologies in this person =
DDx:
- Acute/Chronic medical disorders
- > chronic inflam conditions
- > malignancy
- Psychological conditions
- > Depression / Trauma
- Medications
- > opioids
- > benzos
- > antipsychotics
- Lifestyle
- > Substance use
- > Poor nutrition
- > Poor sleep
Then once that is optimised, I would focus on lifestyle measures and modification to optimise enjoyment of life
- I would start with education with this person and their loved ones about the chronic nature of their fatigue and set realistic expectations
• I would then recommend planned, manageable physical activity using energy conservation measures with pacing, and delegating activities that are not essential or enjoyable
• I would optimise their nutrition
And I would consider whether they need increased supports in the home to reduce the burden of their self-care
