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MED 5 > GP > Flashcards

GP Flashcards

1
Q

Caution in ACEI is in which condition

A

Bilateral renal artery stenosis

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2
Q

Which CCB can you give it heart failure and which one you cant

A

Dihydropyridine- caution in HF and non-Dihydropyridine(verapamil and diltiazem)- can give

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3
Q

In which condition thiazide diuretics should be cautious used

A

Gout

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4
Q

What are the contraindications for beta-blocker

A

asthma, bradycardia, second or third-degree heart block, uncontrolled heart failure

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5
Q

Prazosin is contraindicated in

A

aortic stenosis

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6
Q

Which anti-HTN combination cant you give

A

1) BB + CCB (increase risk of heart block)
2) ACE and ARB
3) ACE +spironolactone(due to risk of hyperkalaemia)

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7
Q

Absolute CV risk assessment recommendation

A

age 35 for ATSI

normal people-45-74

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8
Q

Absolute CV risk assessment factors

A

sex, age, BP, smoking, total cholesterol, HDL cholesterol, T2DM and LVH on ECG

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9
Q

What makes adults are already known to be at increased absolute risk of cardiovascular disease

A

Diabetes and age > 60 years
Diabetes with microalbuminuria (> 20 mcg/min or urinary albumin:creatinine ratio > 2.5 mg/mmol for males, > 3.5 mg/mmol for females)
Moderate or severe chronic kidney disease (persistent proteinuria or estimated glomerular filtration rate < 45 mL/min/1.73 m2)
A previous diagnosis of familial hypercholesterolaemia**
Systolic blood pressure ≥ 180 mmHg or diastolic blood pressure ≥ 110 mmHg
Serum total cholesterol > 7.5 mmol/L

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10
Q

What are 2rd causes of HTN

A

Cushing’s, renal artery stenosis and thyroid disease

CKD, sleep apnea, CoA, Pheochromocytoma and primary adolsteronism

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11
Q

3 conditions to rule out if pt got metabolic syndrome

A

antipsychotic use, PCOS and OSA

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12
Q

Metabolic syndrome criteria- how many need to fulfil

A

3/5

Waist circumference- 102, 88 and 90 and 80
Raised triglycerides ≥1.7mmol/L (or drug treatment for elevated triglycerides)
Reduced HDL cholesterol <1.0mmol/L in men, <1.3mmol/L in women.
Elevated blood pressure (or drug treatment for hypertension) ≥ 130 systolic or ≥85 diastolic.
Elevated Fasting glucose (fasting plasma glucose) ≥5.6 mmol/L or previously diagnosed type 2 diabetes.

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13
Q

Diabetes which risk assessment tool

A

AUSDRISK

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14
Q

AUSDRISK- when can we use it

what is the numbers for high risk

A
  • high risk- from age 40- every 3 years
  • ATSI- from age 18- every 3 years

High risk is greater than 12

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15
Q

What are the screening rates for low and high risk T2DM

A

Those considered at high risk should have an FBG or HbA1c test every three years.

people with low individual risk or who are from a community with low prevalence (<5%) may be screened for risk with AUSDRISK every three years

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16
Q

What are some symptoms of T2DM

A 
Lethargy 
polyuria
polyphagia 
polydipsia
pruritis
Blurred vision 
frequent bacterial or fungal infections 
peripheral neuropathy 
poor wound healing
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17
Q

What are some signs of insulin resistance

A 
Acanthosis Nigricans
Skin tags
central obesity 
PCOS(menstrual irregularities)
Hirsutism
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18
Q

What are the criteria to be met for diagnosing someone with T2DM

A

If they are symptomatic: reading of RBG>11mmol/L or HbA1C greater than 7 is adequate

If asymptomatic:
fasting blood glucose(FBG) >7mmol/L(on two separate occasions)

RBG greater than 11.1 with additional FBG or second HBA1C>6.5

HbA1C>6.5 - on two separate occasions

OGTT:2 hours postprandial >11mmol/L(on two separate occassions)

If diabetes unlikely, repeated test in 3 years

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19
Q

What tool can we use to identify distress in T2DM

A

PAID tool

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20
Q

Which drugs can increase glucose

A

1) Glucocorticoids
2) Immunosuppressants
3) Cytotoxic drugs
4) Antipsychotics

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21
Q

What are the medical emergencies with diabetes(3)

A

Hypoglycemia, DKA and HHS

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22
Q

What are the microvascular complications of diabetes

A

Diabetic nephropathy, retinopathy and neuropathy

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23
Q

What are the macrovascular complications of diabetes

A

CVD, PVD and cerebrovascular disease

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24
Q

HbA1C- what is the cut-off

A

6.5%, if > 6.5 on two separate ocassions diabetes

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25
Q

Diabetes cycle of care

  • every 6 months(4)
  • annually(6)
  • special one
A

Every 6 months

  1. weight, height and BMI
  2. BP
  3. HbA1c
  4. waist circumference

Annual

  1. Measure total cholesterol, triglycerides and HDL-C
  2. Foot exam( high risk- every 6 months)
  3. Microalbuminuria
  4. eGFR
  5. self-care education diet, physical activity and smoking evaluation
  6. medication review

Ensure that a comprehensive eye examination is carried out at least once every 2 years

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26
Q

What are the 4 indications for insulin

A
  1. HbA1c >8.5
  2. Nil improvement of BSL 3 months after being on glucose-lowering medications
  3. Gestational diabetes
  4. If an end-stage renal failure(oral meds are contraindicated)
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27
Q

What are the care plans available for T2DM in GP land

A

NDSS, GPMP+ chronic disease management plan and team care management(TCA)

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28
Q

BSL recommendations for T2DM

A

6-8mmol/L-fasting

8-10-posrprandial

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29
Q

T2DM lipid profile should be

A

Total cholesterol <4
LDL -<2
Triglycerides <2
HDL- >1

4,2,1, rule

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30
Q

Urine albumin excretion T2DM should be

A

male-<2.5

female-<3.5

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31
Q

Metformin 3 SE

A

Lactic acidosis, vitamin b12 deficiency +N/V

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32
Q

Sulfonylurea-insulin secretagogue-SE

A

Hypoglycemia, Weight gain, cannot consume alcohol(Can cause disulfiram-like effect

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33
Q

Thiazoloiniodione(insulin sensitizer)—tazone

A

fluid retention, edema, weight gain, increase heart failure, bone fracture

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34
Q

T2DM in the ward, what is the most important thing

A

diabetes sliding scale

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35
Q

which type of diabetics needs to inform RTA

A

ones who are taking sulphonylureas or insulin

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36
Q

What is the most common cause of visual loss in diabetics

A

Maculopathy

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37
Q

What are 3 causes of sudden blindness

A

central retinal artery, retinal reattachment and vitreous hemorrhage

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38
Q

What are the ddx we should consider for neuropathy

A

Non-diabetic causes of peripheral neuropathy:

b12 deficiency, hypothyroidism, renal disease, excess alcohol consumption and neurotoxic drugs(chemotherapy)

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39
Q

Treatment for diabetic neuropathy

A

antidepressants, anticonvulsants(pregabalin and gabapentin) for neuropathic pain

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40
Q

Autonomic neuropathy is T2DM

A

orthostatic hypotension, gastroparesis and ED and retrograde ejaculation in males

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41
Q

Kidney status in people with T2DM should be assessed how:

A
  1. annual screening for albuminuria(note that dipstick is not adequate to identify albuminuria)
  2. annual eGFR
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42
Q

Screening for microalbuminuria- how, what are the ranges

A

Urine albumin to creatinine ratio(UACR) in a random spot collection-preferred method
Any positive UACR needs to be confirmed with a repeated collection and also mid-stream urine to exclude UTI as a contributor proteinuria

2.5
2.5-25
>25

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43
Q

DO NOT DRIVE UNDER 5

A

check your BSL every 2 hours

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44
Q

Hypoglycemia is below

A

4mmol/L

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45
Q

Things to do in diabetic foot exam

A

neuropathy- 10g monofilament, vibration perception and normal neuro exam

circulation- feel pulses and ABI

foot deformities-

  1. small muscle wasting
  2. Charcot foot deformity
  3. bony prominence
  4. prominent metatarsal hands
  5. hammer of claw toes limited joint mobility
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46
Q

Biochemical criteria for DKA

A

BSL >11
venous pH <7.3
bicarbonate- <15
presence of blood ketones or urinart ketones

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47
Q

HHS-hyperosmolar hyperglycemic state, what should you lookout

A

> 25mmol/L
hyperosmolar
dehydration
change in mental state with little or no ketoacidosis

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48
Q

Tell me about RULE OF 15 with hypoglycemia

A

provide 15g of carbs, wait 15 min

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49
Q

Severe hypo, <2 can result in

A

hypoglycemia coma, resuscitation protocols and injection of glucagon

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50
Q

Non-proliferative changes in Diabetic retinopathy

A

doy haemorrhages, blot haemorrhages, microaneurysms and hard exudates and soft exudates

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51
Q

Proliferative changes diabetic retinopathy

A

neovascularization

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52
Q

unilateral wheeze think

A

inhaled foreign body

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53
Q

When to begin ICS preventer in adults

A

symptoms occur twice per month or more

waking up due to asthma symptoms a least once in the past month

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54
Q

2 conditions which have expiratory wheeze in children

A

asthma and bronchiolitis

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55
Q

Management of COPD exacerbation in GP

A

start using more SABA via MDI and spacer every 3-4 hours, titrate response

Not helping–> oral pred 30-50mg daily for 5 days then stop. If infection present oral antibiotics(augmentin duo) for 5 days

If more than 2 or more exacerbations in a year concerning

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56
Q

Which cancers are reduced by OCP

A

endometrial, ovarian and bowel cancer(BOE)

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57
Q

What are the contraindications for OCP

A
  1. VTE(including obesity)
  2. Stroke(includes migraine with aura)
  3. Ischemic heart disease
  4. Breast cancer
  5. Liver disease

other important considerations- breastfeedings and drug interactions

UpToDate:
●Age ≥35 years and smoking ≥15 cigarettes per day

●Multiple risk factors for arterial cardiovascular disease (such as older age, smoking, diabetes, and hypertension)

●Hypertension (systolic ≥160 mmHg or diastolic ≥100 mmHg)

●Venous thromboembolism

●Known thrombogenic mutations

●Known ischemic heart disease

●History of stroke

●Complicated valvular heart disease (pulmonary hypertension, risk for atrial fibrillation, history of subacute bacterial endocarditis)

●Current breast cancer

●Severe (decompensated) cirrhosis

●Hepatocellular adenoma or malignant hepatoma

●Migraine with aura

●Diabetes mellitus of >20 years duration or with nephropathy, retinopathy, or neuropathy

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58
Q

What is the mechanisms of action of COCP-remember there is estrogen and progesterone

A

The main contraceptive efficacy of COCs is suppression of ovulation by inhibition of gonadotropin-releasing hormone (GnRH), luteinizing hormone (LH), follicle-stimulating hormone (FSH) and the mid-cycle LH surge.

Estrogen suppression of FSH, which in turn prevents folliculogenesis, is likely the most important mechanism

Progestin-related mechanisms that contribute to the contraceptive effect include:

●Effects on the endometrium, rendering it less suitable for implantation. Long-term cyclic or daily progestin exposure leads to endometrial decidualization and eventual atrophy.

●Thickening of cervical mucus, which becomes less permeable to penetration by sperm.

●Impairment of normal tubal motility and peristalsis.

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59
Q

Side effects of COCP

A 
headache
nausea
breast tenderness
unscheduled bleeding 
amenorrhea
acne(usually improves)
bloating 
mood changes 
reduced libidio 
weight gain
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60
Q

When should the pill be started

A

An active hormonal pill should be started on day 1-5 of the menstrual cycle(when bleeding occurs) in order to be immediately effective-the pill is often started >5 days after the onset of menses.

REMEMBER TO EXCLUDE PREGNANCY- do a URINE Beta-hCG
and make sure to
1)TAKE A BP READING
2)MEASURE THEIR BMI–> increased risk of VTE

quick method- will take 7 days for it to start working. IT TAKES 7 DAYS FOR IT TO WORK :) so use other methods of contraception-like condoms or abstinence

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61
Q

Before starting any contraception what should you exclude

A

PREGNANCY!!!

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62
Q

Why post-partum women should not be recommended to use COCP

A

Postpartum women should not use combined hormonal contraceptives for at least the first 21 days after delivery because of the increased risk for venous thromboembolism during this time period

Breastfeeding women should avoid combined hormonal contraceptives until 30 days postpartum due to theoretical effects on lactation.

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63
Q

Doctor, I missed (COCP) one pill today, what should I do?

A

If a single pill is missed anywhere in the packet, women should be instructed to take the missed pill as soon as it is noticed and then continue taking one pill each day as prescribed. Depending on when she remembers her missed pill, she may end up taking two pills on the same day. No additional contraception is required because one missed pill does not reverse ovarian suppression

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64
Q

Doctor, I missed more than 2 pills, what should I do (more than 24 hours)

A

Abstinence from sex or use condoms.

Have unprotected sex after 7 active pills

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65
Q

What does the morning after pill contain

A

levonorgestrel-A synthetic progestogen

The hormone levonorgestrel, at a dose of 1500 micrograms, is taken as soon as possible after unprotected sex. This is supplied as either two tablets (two x 75mg).

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66
Q

GP conditions that are often missed

A
  1. Addison’s disease
  2. Haemochromatosis
  3. Thyroid disease
  4. Menopause
  5. Pregnancy
  6. Diabetes
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67
Q

What are the seven masquerades

A
  1. Depression
  2. Diabetes mellitus
  3. Drugs–> Iatrogenic and self-abuse
  4. Anaemia
  5. Thyroid and other endocrine disorder
  6. Spinal dysfunction
  7. UTI
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68
Q

What are some drugs that can be used to control obesity

A

Duromine

Orlistat

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69
Q

What is the best treatment for obesity

A

Bariatric surgery

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70
Q

CVD risk assessment of <10%, review in

A

BP every 2 years

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71
Q

CVD risk assessment of 10-15%, review in

A

BP every 6-12 months

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72
Q

CVD risk assessment of >15%, review in

A

BP every 6-12 weeks

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73
Q

What are some yellow flags of lower back pain

A
  1. The belief that pain and activity are harmful
  2. “Sickness behaviour(like extended rest)
  3. Low or negative mood, social withdrawal
  4. History of back pain, time-off and other claims
  5. Overprotective family vs lack of support
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74
Q

Menopause

A

diagnosed after 12 months of amenorrhea.

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75
Q

Benefits vs the risk of HRT

A

cons: risk of breast cancer and endometrial , CHD, stroke, DVT and PE
pros: reduce osteoporotic fracture

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76
Q

What are some examples of bisphosphonates

A

Alendronate, risedrionate and zoledronic acid

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77
Q

What are the 4 important side effects of bisphosphonates

A

hypocalcemia
renal impairment
aseptic osteonecrosis of the jaw
esophageal inflammation and increase risk of cancer

78
Q

What advice do you need to give to patient taking bisphosphonates

A

Bisphosphonates should be taken in the morning with sufficient water and in an upright position at least 60 minutes before eating!

and SHOULD NOT be taken with calcium supplementation

79
Q

What are some contraindications for bisphosphonates

A

Reduced GFR (< 30–35 ml/min)
Hypocalcemia
Esophageal abnormalities (e.g., strictures)
Pregnancy/lactation period: no clear contraindications, individual risks/benefits must be weighed

80
Q

Prolia (Denosumab Injection)

A

Denosumab is recommended for osteoporosis in post-menopausal women at increased risk of minimal trauma fracture

Every 6 months

if treatment stops, osteoporosis will come back

81
Q

What is the gold standard for measuring the bone mineral density in Australia

A

DXA

DXA is a diagnostic tool for osteoporosis or osteopenia, enabling doctors to determine the extent of bone loss for
clinical decision making

82
Q

If suspected of a vertebral fracture, when should refer it on

A

Refer for spinal X-ray when:
– Height loss of 3cm or more
– Thoracic kyphosis
– New onset back pain suggestive of fracture

if the fracture is confirmed then do a DXA scan

83
Q

What does T score signify

A

The T-score compares the patient’s bone density to the peak bone density of young adults. It is the number of standard deviations (SDs) of the BMD measurement above or below that of young healthy adults of the same sex. According to definitions agreed by the World Health Organisation, a T-score of -2.5 or lower at the spine or hip is indicative of osteoporosis

-reference with a healthy 30-year-old

84
Q

What does Z score signify

A

The Z-score compares the patient’s bone density to that of
adults of the same age. It is the number of SDs of the BMD
measurement above or below that of adults of the same age and sex. Z-score is a useful indicator of possible secondary osteoporosis. A Z-score of -2.0 or below should trigger investigations for the underlying disease to exclude other causes of bone mineral loss.

-age-matched normal

85
Q

Only patients over 70 need a bone density test with DXA, is it true doc?

A

Clinical risk factors – not age – should determine referral for DXA, targeting the 50+ patient population is important.

Prevention is key

86
Q

Please draw out the osteoporosis treatment algorithm

A

https://www.osteoporosis.org.au/
sites/default/files/files/RACGP%20Osteoporosis%20Summary%20
Guideline%204428%20Nov%202017.pdf

87
Q

What are the 2 fracture calculator Australia uses

A

Garvan Fracture Risk Calculator or FRAX

88
Q

When should a full falls risk assessment be done

A

Any person who has fallen twice or more in the previous 12 months or having difficulty with walking or balance.

A multifaceted falls prevention program should be tailored to individual needs.

89
Q

What type of exercise is recommended for improving bone density

A

Not leisure walking, swimming or cycling

prescribed regular, varied, high-intensity resistance training and progressive balance training.

programs should be individualized

90
Q

Which glaucoma presents as acute onset

A

closed-angle glaucoma

91
Q

Osteoporosis- what is the most common site for fractures–> go from most to least

A

vertebral (most common) > femoral neck > distal radius (Colles) fracture, fractures of the long bones (e.g., humerus)

92
Q

How would you detect a vertebral factures-Osteoporosis

A

Vertebral compression (crush) fractures are commonly asymptomatic but may cause acute back pain and possible point tenderness without neurological symptoms

Long-term findings after repeated vertebral compression fractures
→ Decreased height (loss of 2–3 cm with each fracture)
→ Thoracic hyperkyphosis → stooped posture with a “dowager’s hump”

93
Q

4 ddx for osteoporosis

A

Osteomalacia
Hyperparathyroidism
Metastases
Multiple myeloma

94
Q

What is first-line for osteoporosis

A

1st-line treatment: bisphosphonates (alendronate, risedronate); inhibit osteoclasts and therefore bone resorption

95
Q

Why should you give raloxifene to a woman who has osteoporosis

A

Raloxifene (selective estrogen receptor modulator, SERM) for patients with contraindications to bisphosphonates or those who also require breast cancer prophylaxis (but increases the risk of thromboembolism

96
Q

State some things you would consider in the management as a GP

A

Primary prevention - GP centered

implement strategies to prevent falls

  • improving vision
  • adjusting drug therapy if possible (eg drugs causing sedation, altered gait or postural hypotension)
  • minimising household risks (preferably under the guidance of an occupational therapist)
  • providing aids for daily living (eg walking aids, rails)
  • minimising periods of immobilisation
  • promoting exercise to maintain mobility, balance and strength.

increase weight-bearing exercise and balance training

ensure adequate calcium intake

ensure vitamin D sufficiency

stop smoking

limit alcohol intake to two standard drinks per day

maintain ideal body weight.

97
Q

What is the frequency of

  • prolia injection
  • bisphosphonates
A
  • bisphosphonates is once week tablet
  • Denosumab- SC injection/ 6 monthly

eTG

98
Q

What are the causes of falls in the elderly

A

Motor problems: gait or balance impairment; muscle weakness

Sensory impairment: peripheral neuropathy, vestibular dysfunction, vision impairment

Cognitive or mood impairment: dementia, depression, delirium

Orthostatic hypotension

Polypharmacy or certain medicines (particularly psychotropic medicines)

Impairment of activities of daily living

Environmental hazards (e.g., loose rugs, poor lighting, clutter)

Additional factors such as age or comorbid illnesses.[

99
Q

Falls history should assess

A

Location

Activity at the time of the fall

Injury realted to the fall

Any change in level, or LOC

Cardiovascular symptoms–> chest pain, palpitations, dizziness, vertigo or lightheadedness

Symptoms related to change–> spine to sitting, sitting to standing

Pain or neurological symptoms( headache, weakness/tingling/numbness or acute change in mental status), which may indicate an underlying acute condition such as stroke

Medicines should be reviewed (with particular reference to psychotropic medications and narcotics
falls with related head injury should prompt a re-evaluation of risk for individuals taking anticoagulants or antiplatelet therapy).

A history of comorbidities such as diabetes, Parkinson’s disease or osteoporosis should be elicited.

Coordination and cerebellar function testing is useful when looking for focal deficits related to cerebrovascular disease or neurodegenerative disorders such as corticobasal degeneration.

Consider Romberg’s sign and tests for proprioception when the patient complains of balance problems or if there are underlying causes of peripheral neuropathy (e.g., diabetes, B12 deficiency).

Dix-Hallpike manoeuvre

100
Q

Red flags to rule out in dementia

A
  • Delirium
  • Depression
  • Brain tumours
  • Traumatic brain injury
  • Tuberculosis
  • Syphilis (late)

Normal pressure hydrocephalus

MAKE SURE TO ASK ABOUT ACTIVITIES OF DAILY LIVING–> shopping, driving car, cleaning

101
Q

Common ddx with dementia

A 
Mild cognitive impairment (MCI) Delirium
Depression
Alzheimer's dementia
Vascular dementia 
Lewy body dementia
102
Q

CAM algorithm for diagnosis of delirium

A

2 of these must be present

  1. Acute onset or fluctuating course and
  2. Inattention and

Either 3. Disorganized thinking
4. Altered level of consciousness

103
Q

Can you diagnose dementia

A

NO it is a symptom. It is under the umbrella term of Makor neurocognitive disorder. You need to find the cause of it

104
Q

State some causes of dementia

A 
Alzheimer's disease
Vascular dementia 
Mixed(vd+ad)
Frontotemporal disease--> with or without pick's bodies
Dementia with Lewy bodies 
Parkinson's disease with dementia 
Huntington's disease
105
Q

What are some treatable dementia-MINDWAVES

A 
Meningioma and other tumours
Infection--> neurosyphilis
Normal-pressure hydrocephalus
Depression
Wilson's disease
Alcohol and drugs
Vitamin b12 deficiency
Endocrine--> hypothyroidism
Subdural haematoma
106
Q

How can we assess for dementia

A

MMSE
ACE-R
FAB
RUDAS

107
Q

What cognitive assessment tool can we use for dementia in ATSI

A

KICA-Kimberley Indigenous Cognitive Assessment (KICA)

108
Q

Medications that can help with slowing down dementia

A

Cholinesterase inhibitors
Memantine

In general, anticholinergic substances (e.g., tricyclic antidepressants) should be avoided, as they may lead to further deterioration in cognitive functioning!

109
Q

Advice on scabies on treatment to the patient

-what the difference in infants and adults in applying

A

irst-line treatment for scabies is topical permethrin 5% cream, which should be applied to the whole body (excluding the head and neck in patients other than infants) and washed off after eight hours.

All household contacts should be treated at the same time.

If the first application is thorough, then no repeat dose is required, as permethrin is active against all stages of the parasite’s life cycle. If symptoms persist, we recommend a repeat application 7–14 days after the first treatment.

110
Q

If the 1st line treatment for scabies does not work, what is the 2nd line options

A

Benzyl benzoate 25% is the second-line topical agent. It commonly causes skin irritation, and should be diluted with water for children and infants It is applied and then left for 24 hours before being washed off.

111
Q

The patient who has chronic kidney disease has low Hb?

What can be the cause of this and what is the management for this patient

A

Anemia of chronic kidney disease: ↓ hemoglobin, ↔︎ MCV
Pathophysiology: ↓ erythropoietin → decreased stimulation of RBC production → normocytic, normochromic anemia
(Additionally, uremia causes hemolysis, coagulopathies, and inhibits erythropoiesis)

Administer synthetic EPO, possibly in conjunction with iron replacement depending on serum ferritin and transferrin values.
Adverse effects: increased risk of thrombosis, increase in blood pressure
May need RBC transfusion- under consultant review

112
Q

Hypocalcemia in CKD is caused by what?

A

Decreased production of vitamin D and hyperphosphatemia causes hypocalcemia.

Patients develop secondary hyperparathyroidism and subsequent renal osteodystrophy due to hyperphosphatemia, hypocalcemia, and the insufficient production of vitamin D!

Can monitor PTH and calcitriol

113
Q

Sorethroat- if possible do what?

A

Do a throat swab if possible

Rapid antigen test- if available is really good too

114
Q

Wha are the importances of falls

A

1) Disability
2) Instiutuionalization
3) Mortality
4) Socioeconomic burden

115
Q

Intrinsic vs extrinsic factors for falls- what the reason

A

Intrinisic- patient factors

Extrinsic- environmental

116
Q

The strongest predictor for falls

A

Prior falls

117
Q

What are the geriatric syndromes

A

1) Cognition-3Ds
2) Bowels and bladder
3) Sleep- sleep disturbances
4) Sensory - hearing and vision
5) Mobility-immobility and gait disturbances. Falls and fragility fractures. pain(osteoarthritis)
6) Diet and weight
7) Polypharmacy

Rule out cardiac syncope

118
Q

What delirium screening can I use for elderly people

A

The 4A Test: screening instrument for cognitive impairment and delirium

119
Q

Falls prevention in older adults-5

A 
Exercise
High dose vitamin D	
Psychoactive medication withdrawal AND Medication 
review by pharmacist
Occupational therapy home visit
Restricted multifocal spectacle use
Expedited cataract surgery
Podiatry intervention
120
Q

Skin cancer- what are the two main types

A

Melanoma–> from melanocytes

Non-melanocytic skin cancer (NMSC):

1) SCC
2) BCC

developed from keratinocytes

121
Q

___________ and _________ are associated with both
amount and pattern of sun exposure, with an
intermittent pattern carrying the highest risk.

A

Melanoma and BCC are associated with both
amount and pattern of sun exposure, with an
intermittent pattern carrying the highest risk.

122
Q

_____________ and ________ are
associated with the total amount of sun
exposure accumulated over a lifetime

A

Premalignant actinic keratosis and SCC are
associated with the total amount of sun
exposure accumulated over a lifetime

123
Q

Risk factors for melanoma

A

• Personal history of melanoma
• Multiple dysplastic naevi (>5)
• Multiple naevi (>100 or >11 on arm)
• Family history of melanoma/Personal
history of NMSC
• Having fair or red hair and blue or green eyes
• Fair skin that burns easily, freckles and does
not tan
• High levels of intermittent sun exposure (e.g.
during outdoor recreation or sunny holidays)
• Immune suppression and/or transplant recipients
• Increasing age

124
Q

5 S to prevent from skin cancer

A

Slip-on sun-protective clothing – that covers as much skin as possible.

Slop on SPF30 (or higher) sunscreen – make sure it is broad-spectrum and water-resistant.

Slap on a hat – that protects the face, head, neck and ears.

Seek shade.

Slide on sunglasses

Check the daily sun protection times on the free
SunSmart app

125
Q

The ABCDE acronym can help distinguish a superficial spreading melanoma from a normal mole:

A

Asymmetry: the lesion is irregular in shape or pattern.

Border: the border or outline of a melanoma is usually irregular

Colour: there is variation in colour within the lesion

Diameter: the lesion is usually greater than 6 mm across. However, suspect lesions of smaller diameter should also be investigated

Evolving: the lesion changes over time (size, shape, surface, colour, symptoms e.g. itch).

126
Q

What is an aggressive form of melanoma

A

This is an aggressive form of melanoma that grows quickly.

127
Q

The ABCDE acronym cannot be used
to aid diagnosis of nodular melanoma;
however, the following features can be
of help:

A

Elevated: the lesion can appear as a small, round
and raised lump on the skin. Colour may be
uniform throughout the lesion and may be black,
brown, pink or red.

Firm: the lesion feels firm to touch.

Growing: a nodule that has been growing
progressively for more than a month should be
assessed as a matter of urgency

128
Q

Is nodular melanoma a GP emergency

A

YES, If nodular melanoma is suspected, the diagnosis should not be delayed, and urgent referral to a dermatologist or immediate excision is recommended.

NM can become life-threatening in 6–8 weeks.

129
Q

Selecting appropriate primary treatment will

depend on the

A

Breslow thickness (vertical depth) of the tumour

130
Q

Treatment options for non-melanoma

skin cancer include:5

A 
• Surgical excision of the tumour and
surrounding tissue
• Curettage and cautery
• Application of topical agents (imiquimod
cream, fluorouracil cream, photodynamic
therapy)
• Cryotherapy
• Radiotherapy
131
Q

Bowen disease

A

Squamous cell carcinoma in situ, or Bowen disease, is an early form
of skin cancer that begins in the top layer of the skin (epidermis). It
looks like a red, scaly patch and can develop into invasive squamous
cell carcinoma if left untreated. The diagnosis and treatment of
squamous cell carcinoma in situ is similar to BCC and SCC.

132
Q

Sunspots (solar or actinic keratoses) - are they a risk factor

A

Anyone can develop sunspots, but they occur more often in people over 40, generally on skin that’s frequently exposed to the sun,

such as the head, neck, hands, forearms and legs.
They are a warning sign that the skin has had too much
sun exposure, increasing the risk of skin cancer.

133
Q

imiquimod
(brand name, Aldara)
- what can it be used for

A

Sunspots
superficial BCCs
squamous cell carcinoma in situ (Bowen disease)

You apply imiquimod directly to the affected area once a day at night, usually five days a week for six weeks

134
Q

Arborizing vessels (AVs)

A

Arborizing vessels (AVs) are dermoscopically defined as telangiectasias with distinct treelike branching, and are a characteristic feature of basal cell carcinoma (BCC).

135
Q

Intraepidermal squamous cell carcinoma (SCC)

A

Intraepidermal squamous cell carcinoma (SCC) is a common superficial form of skin cancer. It is also known as Bowen disease, intraepidermal carcinoma (IEC) and carcinoma in situ (SCC in situ).

136
Q

BCC margin

A

3mm

137
Q

SCC margin

A

4mm

138
Q

the only treatment for SCC

A

surgery only

139
Q

idara and efudix which ones can we use it on- BCC/SCC and where can we use on the body

A

NOT ON THE FACE

ONLY FOR BCC and bowen disease

140
Q

melanoma is _____ mm

A

equal or >6mm

141
Q

solar and actinic kertaosis- treatment of option

A

Cryotherapy

142
Q

Tell me the NHMRC margins for these melanoma
in-situ

<1mm
1-2mm
2-4mm

greater than 4

A

in-situ- 5m mmargin

1-4– 1cm margin

4+ is 2 cm margin

143
Q

Misoprostol actions on the female reproductive system?

A

It causes uterine contractions AND cervical ripening (dilation).

144
Q

3 main causes of CKD

A

1) T2DM
2) HTN
3) glomerulonephritis

145
Q

State some clinical features of CKD

A

Patients are often asymptomatic until later stages.

  1. Hypertension
  2. Peripheral edema
  3. Pulmonary edema (usually interstitial pulmonary edema)
Clinical features of uremia 
Fatigue, weakness, loss of appetite, headaches
Uremic fetor
Pigmented spots
Pruritus 
Anemia
Uremic pericarditis
Pleuritis
Asterixis
Encephalopathy: seizures, somnolence, coma
Peripheral neuropathy: paresthesias
Gastrointestinal symptoms: nausea, vomiting

↑ Risk of infection: leukocyte dysfunction

↑ Bleeding tendency secondary to platelet dysfunction

146
Q

Why does CKD increase

  • anaemia
  • bone damage
  • bleeding problems
  • immunosuppression
A

↑ Risk of infection: leukocyte dysfunction

↑ Bleeding tendency secondary to platelet dysfunction

Chronic kidney disease-mineral and bone disorder (CKD-MBD): abnormalities of mineral or bone metabolism in the setting of chronic renal disease
Etiology: mostly due to secondary hyperparathyroidism → high-turnover renal osteodystrophy or osteitis fibrosa cystica
Clinical features: weakness, fractures, bone pain, avascular necrosis

Anemia of chronic kidney disease: ↓ hemoglobin, ↔︎ MCV
Pathophysiology: ↓ erythropoietin → decreased stimulation of RBC production → normocytic, normochromic anemi

147
Q

When do you repeat UCR and eGFR in diabetics and HTN

A

If urine ACR and eGFR are normal repeat Kidney Health Check in 1-2 years (annually if diabetes or hypertension present)

148
Q

Tell me the normal vs mirco and macro

A

Normal
(urine ACR mg/mmol)
Male: < 2.5
Female: < 3.5

Microalbuminuria
(urine ACR mg/mmol)
Male: < 2.5 -25
Female: < 3.5-35

Macroalbuminuria
(urine ACR mg/mmol)
Male: > 25
Female: > 35

149
Q

When do you worry about the eGFR

A

eGFR < 60 if less than this repeat in 7 days,

if that eGFR reduced by 20%–> ?AKI

if stable–> repeated twice in 3months

YOU NEED Minimum 3 reduced eGFR’s
present for ≥3 months for CKD

150
Q

defintion of CKD

A

an estimated or measured glomerular filtration rate (GFR) < 60 mL/min/1.73m2
that
is present for ≥3 months with or without evidence of kidney damage

151
Q

Blood Pressure Targets for patient with

1) CKD
2) CKD with diabetes+ mircoabluminuria

A

CKD–> 140/90

CKD with diabetes+ mircoabluminuria–> 130/80

152
Q

In CKD which electrolyte levels are we worried about

A

In chronic renal disease, close surveillance of serum potassium values as well as calcium and phosphate values is essential!

153
Q

Anemia of chronic kidney disease treatment

A

Administer synthetic EPO, possibly in conjunction with iron replacement depending on serum ferritin and transferrin values.
Adverse effects: increased risk of thrombosis, increase in blood pressure

154
Q

What is the effect HTN has on the kidneys

A

Hypertensive nephrosclerosis

chronic hypertension → narrowing of afferent and efferent arterioles → reduction of glomerular blood flow → glomerular and tubular ischemia → arteriolonephrosclerosis and fibrosis (focal segmental glomerulosclerosis) → end-stage renal disease

It is a vicious cycle

155
Q

HTN retinopathy- state some changes

A

cotton-wool spots, retinal hemorrhages (i.e., flame-shaped hemorrhages), arteriovenous nicking , marked swelling and prominence of the optic disk with indistinct borders due to papilledema and optic atrophy (end-stage disease)

156
Q

Hypertensive crisis (acute severe hypertension)

A

Definition: acute increase in blood pressure > 180/120 mm Hg

157
Q

Malignant hypertension- definition

A

EMERGENCY

Malignant hypertension: severe hypertension that occurs with retinopathy (flame hemorrhages, papilledema)

A person with malignant hypertension has a blood pressure that’s typically above 180/120. Malignant hypertension should be treated as a medical emergency.

158
Q

Which drugs are used to treat people in hypertensive crisis(IV basically)

A

The most commonly used drugs to treat hypertensive emergency are nitroprusside, labetalol, and nicardipine.

159
Q

Nephritic syndrome features-5

A 
Proteinuria (< 3.5 g/day)
Hematuria with acanthocytes
Mild to moderate edema
RBC casts in urine
Oliguria
Azotemia
Hypertension
Sterile pyuria
160
Q

Nephrotic syndrome features-5

A 
Heavy proteinuria (> 3.5 g/day)
Hypoalbuminemia
Generalized edema
Hyperlipidemia and fatty casts in urine
Hypertension
↑ Risk of thromboembolism and infection
161
Q

What time of glomerular disease does T2DM cause of the kidney

A

Nephrotic syndrome

All glomerular diseases can lead to acute and chronic kidney failure!

162
Q

Necrotizing fasciitis

A

Pathogen: group A Streptococcus ; frequently mixed infection (with aerobic and anaerobic gram-negative bacteria)

Gas gangrene is a type of necrotizing fasciitis caused by Clostridium perfringens

163
Q

Endothelial cell dysfunction due to bacterial toxins

A

HUS

164
Q

ADAMTS13 deficiency

A

TTP

165
Q

Antiplatelet antibodies (Anti-GpIIb/IIIa)

A

ITP( diagnosis of exlcusion)

166
Q

Macrolides

A

-thromycin

think ACE (Azithromycin, Clarithromycin, Erythromycin)

> > QT Prolongation, GI distress/C. diff

167
Q

What is the most common cause of pulmonary HTN?

A

Chronic damage due to lung disease –> cor pulmonale

i.e. COPD

168
Q

What is grade 1 hypertensive retinopathy?

A

Thickening of arterioles

169
Q

What is grade 2 hypertensive retinopathy?

A

Focal arteriolar spasms (AV nipping)

170
Q

What is grade 3 hypertensive retinopathy?

A

Haemorrhages (flame shaped)
Exudates (cotton wool)
Waxy exudates

171
Q

What is grade 4 hypertensive retinopathy?

A

Papilloedema

172
Q

What does the pattern of oedema suggest about the side of the heart affected?

A

Right sided failure = peripheral oedema

Left sided failure = pulmonary oedema

173
Q

What does the pattern of oedema suggest about the side of the heart affected?

A

Right-sided failure = peripheral oedema

Left-sided failure = pulmonary oedema

174
Q

What are the modifiable CVD risk factors

A 
Smoking status
Nutrition and diet 
Alcohol intake 
Level of physical activity 
BP
Waist circumference and BMI 
Serum lipids
175
Q

Other related condition that increase your CVD risk-4

A
  1. Diabetes
  2. Chronic Kidney Disease (albuminuria ± urine protein, eGFR)
  3. Familial hypercholesterolaemia#
  4. Evidence of atrial fibrillation (history, examination, electrocardiogram)
176
Q

Other related condition that increases your CVD risk-4

A
  1. Diabetes
  2. Chronic Kidney Disease (albuminuria ± urine protein, eGFR)
  3. Familial hypercholesterolaemia#
  4. Evidence of atrial fibrillation (history, examination, electrocardiogram)
177
Q

Warfarin MoA

-pre-op

A

Vitamin K antagonists (coumarins

Vitamin K antagonists inhibit the enzyme vitamin K epoxide reductase, thereby blocking hepatic synthesis of the active, reduced form of vitamin K (needed for carboxylation of coagulation factors II, VII, IX, and X, protein C, protein S).

Can give vitamin K PO if INR is not less than 1.5 prior to surgery

pre-op
Warfarin – usually stopped 5 days prior to surgery due to bleeding risk and commenced on therapeutic dose low molecular weight heparin
Surgery will often only go ahead if the INR <1.5, so you may have to reverse the warfarinisation with PO Vitamin K if the INR remains high on the evening before

178
Q

Dabigatran moa

A

Direct thrombin inhibitors

179
Q

rivaroxaban and apixaban-MoA

A

Factor Xa inhibitor

180
Q

Aspirin- anticoagulation MoA

A

Inhibits thromboxane A2 synthesis by irreversibly acetylating cyclooxygenase-1 in platelets and megakaryocyte

IRREVERSIBLE inhibition of COX-1

181
Q

Preoperative bridging therapy

A
  1. Stop coumarin administration 5–6 days before surgery.
  2. Administer a therapeutic dose of the bridging drug 3 days before surgery, with the last dose administered 24 hours before the procedure.
  3. Resume the bridging drug and warfarin after surgery ; administer the bridging drug for 4–6 days post-surgery
182
Q

NSAIDs (general) MoA

A

Inhibit cyclooxygenase 1 & 2 (COX-1/COX-2), thus preventing the conversion of arachidonic acid to prostaglandin, a key mediator in inflammation

and Inhibits thromboxane A2 synthesis by irreversibly acetylating cyclooxygenase-1 in platelets and megakaryocyte

aspirin is a type of NSAIDs

183
Q

Aspirin is considered an anticoagulant or NSAIDs

A

BOTH

the anticoagulant effect due to the antiplatelet effect

Anticoagulants such as heparin or warfarin (also called Coumadin) slow down your body’s process of making clots. Antiplatelet drugs, such as aspirin, prevent blood cells called platelets from clumping together to form a clot.

184
Q

Aspirin overdose (salicylate toxicity

A

tinnitus, tachypnea, vomiting, and a characteristic mixed respiratory alkalosis and metabolic acidosis on ABG.

185
Q

What is clopidogrel used for

A

P2Y12 receptor antagonists (clopidogrel, prasugrel, ticagrelor) are mainly used in conjunction with aspirin (dual antiplatelet therapy) in the management of acute coronary syndrome and to prevent rethrombosis in patients after percutaneous coronary intervention (PCI) and/or stenting.

186
Q

Aspirin

A

Irreversible COX-1 inhibition → inhibition of thromboxane (TXA2) synthesis in platelets → inhibition of platelet aggregation (antithrombotic effect)

Irreversible COX-1 and COX-2 inhibition → inhibition of prostacyclin and prostaglandin synthesis → antipyretic, anti-inflammatory, and analgesic effect

187
Q

Signs and symptoms specific to DKA

A 
Rapid onset (< 24 h) in contrast to HHS 
Abdominal pain 
Fruity odor on the breath (from exhaled acetone) 
Hyperventilation: Kussmaul respirations: deep breaths at a normal respiratory rate
188
Q

DKA chart- what is the special blood test you do

A

Blood culture

beta-hCG( if women and pregnant)–> can do this with urine–> cause pregnant with DKA–> immediate ICU admission

189
Q

Eyes in diabetics

A

1) diabetic retinopathy

2) cataract

190
Q

The most common cause of AKI

A

Pre-renal failure

191
Q

The most common cause of pre-renal failure

A

Acute tubular necrosis

Muddy brown casts

MED 5 (23 decks)

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