High Yield

Question 1

How would you approach Babak’s chronic pain?

Answer 1

1. Multidisciplinary approach, manage expectations
2. Determine cause and nature of pain and comment about impact
3. Non-pharmacological
   - Psych - CBT/Mental health
   - Diet - Weight loss
   - OT - home setup/gait aid
   - Physio- exercise program/hydrotherapy
   - Alt - heat pack/massage/acupuncture
4. Multi-modal analgesia
5. Pain clinic/palliative care
6. Procedural/radiotherapy

Question 2

What are some potential causes of Babak’s falls?

Answer 2

1. intrinsic factors
   - visual impairment
   - peripheral neuropathy
   - postural hypotension
   - neurological
   - incontinence
   - cognition
2. extrinsic factors
   - polypharmacy
   - clutter
   - home environment
   - substance abuse
   - inappropriate gait aid

Question 3

How would you reduce Babak’s risk of falls

Answer 3

1. Identify contributing factors
   - General: Vision, balance, dizzy, toileting
   - Environment/gait aids
   - Comorbidities
   - Medication
2. Non-pharmacological
   - falls and balance training
   - physiotherapy
   - OT home assessment and modification
   - medication review
3. Pharmacological
   - manage osteoporosis
   - anticoagulation risk

Question 4

How would you improve Babak’s poor compliance?

Answer 4

1. Statement about how this has impacted their care

2. Identify barriers 
Patient factors
- insight
- education
- cognition
- cultural
- poor mental health 

External factors

• access to healthcare
• multiple providers
• polypharmacy/drug side effects
• finances

3. Management
   - education, programs, written information
   - involve family
   - webster packs
   - manage depression
   - centralise care/telehealth
   - simplify treatment regime
   - healthcare cards/social work

Question 5

Steroid side effects

Answer 5

1. Use lowest dose for shortest duration possible
2. Screen for complications
   - psychiatric
   - cataract/glaucoma
   - osteoporosis
   - diabetes/weight gain/hypertension
   - infection
   - myopathy
   - skin/ulcers
3. Manage accordingly

Question 6

How would you balance Babak’s risk of bleeding/indication for anticoagulation?

Answer 6

1. Review indication for anticoagulation
   - ACS/CHADS2VASC
   - comment on medication profile/reversal agents
2. Bleeding risk
   - current active bleed, prior bleeds
   - HASBLED, alcohol
   - falls risk
3. Multidisciplinary discussion with pt to decide, but provide your opinion
4. Consider left atrial appendage occlusion devices

Question 7

What would be your approach to Babak’s obesity?

Answer 7

1. Comment about contemplative stage
2. Identify barriers
   - mental health
   - sedentary lifestyle
   - physical barriers
   - drugs
3. Set weight loss targets (realistic) and follow-up
   - 1kg/week
   - goal is to achieve 5 - 10% weight loss in 6 months
4. Non-pharmacological
   - low caloric diet
   - optifast (meal replacement)
   - regular exercise (programs)
5. Pharmacological
   - orlistat
   - GLP-1
6. Bariatric surgery

Question 8

Bariatric surgery: Indications and contra-indications

Answer 8

Indications

• BMI > 40
• BMI > 35 with complications (includes T2DM)
• improvement to QOL/comorbidities

Contra-indications

• high perioperative risk
• poor mental health/substance abuse
• inability to adhere to dietary requirements
• functional status

Question 9

What would be your approach to smoking cessation in Babs?

Answer 9

1. Comment on contemplative stage
2. Identify dependence (physiological, psychological)
3. Identify barriers
   - mental health
   - social (family)
4. Set goals and follow-up
5. Non-pharmacological
   - education (involve family, health benefits, cost benefits)
   - Quit-line
   - Quit-Smoking Aus App
6. Pharmacological
   - combination NRT
   - varenicline
   - bupropion

Question 10

How would you help Babak cease drinking alcohol?

Answer 10

1. Comment on contemplative stage
2. Identify dependence (withdrawal, CAGE, pathological)
3. Identify barriers
   - mental health
   - social
4. Set goals and follow-up
5. Non-pharmacological
   - AA
   - drug and alcohol services (detox/rehab)
6. Pharmacological
   - naltrexone
   - acamprosate
   - disulfiram

Question 11

Fatigue (causes)

Answer 11

Common

1. sleep disorder
2. anaemia
3. hypothyroidism
4. cardiopulmonary - exertional dyspnoea
5. obesity, deconditioning
6. medications
7. substance use
8. psychological - depression, anxiety, PMR
9. chronic pain
10. malnutrition

Tailored

1. adrenal insufficiency
2. chronic renal disease
3. chronic liver failure
4. electrolyte disturbances
5. occult malignancy
6. chronic infectious diseases
7. rheumatological - fibromyalgia, PMR
8. chronic neurological dx

Question 12

Pre-conception counselling

Answer 12

1. Identify risk - is pregnancy contraindicated
2. Pre-pregnancy counselling and fertility counselling
   - education with high-risk obstetrician and specialists
   - risk to mother and baby
   - Consider surrogacy/adoption
3. Contraception - importance of planned pregnancy
4. Review, monitor and control comorbidities (level of disease of activity)
5. Medications review, folate supplementation
6. Monitoring intrapartum with more frequent reviews
7. Deliver in a tertiary centre
8. Consideration about fertility/ovulatory/egg harvesting

Question 13

Multi factorial dyspnoea

Answer 13

Cardiac
- Ischaemic
- CCF
- Pulm HTN
Respiratory
Infection
Malignancy
Obesity
Thrombosis
Mental Health

Question 14

Future planning/ advance care plan

Answer 14

1. Recognition of prognosis
2. Patient wishes/ACP
   - Discussion + documentation with patient re wishes for EOLC
   - Involvement of family to be aware and assist with facilitating wishes
   - Discussion re location for EOLC- Home, Hospice, RACF, hospital
   - Formal appointment of MPOA + finalisation of will
3. Maintaining QOL
   - Palliative care services for support and symptoms
   - What is possible at home if this is their wishes- A/H to facilitate, are family able/willing to assist
   - Review ongoing need for further input- SP- swallowing, mobility aids/home equipment
4. Support for patient and family
   - Social work, support groups, psychological/mental health counselling, respite
   - Education for patient and family re what to expect and who to contact for assistance

Question 15

Infection vs immunity

Answer 15

1. Executive statement about level of immunosuppression/indication and impact of infections
2. Infection
   - treat current infection
   - review anatomical anomalies
   - review microbiological tests
   - non-pharmacological - education (sick day plan)
   - pharmacological - vaccinations, antibiotics
   - prophylaxis
   - emergency antibiotic supply
3. Immunity
   - indication for immunosuppression
   - review drugs levels
   - review cell counts
   - review immunoglobulin levels
   - involve transplant/specialist in rationalising dose with careful monitoring

Question 16

Driving

Answer 16

1. Identify factors that contribute to risk
   - OSA
   - insulin use
   - stroke/seizure
   - cardiac events
   - syncope
2. Understand impact this has on patient (commercial/private)
3. General assessment
   - visual acuity 6/12
   - occupational driving assessment
   - review the local guidelines
4. Education
   - BSL > 5 to drive
5. Support
   - taxi vouchers
   - family members
   - meals on wheels

Question 17

Impotence

Answer 17

1. Contributing factors
   - smoking
   - alcohol
   - lack of exercise
   - psychological
   - cardiovascular disease
   - autonomic dysfunction - diabetes
   - neurological
   - SSRi, anti-testosterone agents
2. Understand impact on relationships, mental health, performance anxiety - now an emotional companion
3. Build therapeutic relationship, organise follow-up
4. Investigate
   - glycemic control
   - testosterone
5. Non-pharmacological
   - counselling
   - lifestyle
   - medication review
   - psychosocial
6. Pharmacological
   - sildenafil (beware GTN)

Question 18

Depression

Answer 18

1. Identify contributing factors and understand impact of depression on overall QOL and adherence
   - substance abuse
   - organic - TSH, prednisolone
2. Non-pharmacological
   - reassurance and support
   - CBT (psychologist)
   - general nutrition
   - sleep hygiene
   - augmenting community supports
   - involving family
   - support group
3. Pharmacological
   - SSRIs
   - Psychiatrist
4. Regular follow-up
   - GP mental health plan

Question 19

Transplant work up

Answer 19

1. Can he/she survive surgery? (Perioperative risk)
2. Expected survival rate? (Non-renal comorbidities)
3. Can they have immunosuppression? (Infection, malignancy - 5 years except skin/RCC)
4. Psychosocial barriers
5. Surgical factors (BMI, PVD, PCKD)
6. Immunological factors (minimise sensitising events)

Question 20

Hyperglycaemia

Answer 20

1. Contributors of hyperglycaemia
   - drugs (steroids)
   - lifestyle
   - poor engagement/adherence to therapy
2. Establish level of glycemic control (based on complications) and understand impact
3. Investigate
   - interrogate glucometer
   - review BSL diary
   - HbA1c
4. Non-pharmacological
   - dietitian - carbohydrate counting, low GI
   - exercise - moderate intensity, 30 minutes x 5days
   - education, DNE support
   - review technique (ensuring adequate rotation of sites, not withdrawing the needle before injecting, vision)
5. Pharmacological
   - titrate insulin
   - simplify regime
   - intensify regime (basal bolus)
   - additional oral hypoglycaemic agents
   - continuous glucose monitoring
   - review contributing factors (wean steroids)

Question 21

Hypoglycaemia

Answer 21

1. Contributors of hypoglycaemia and recognise impact
   - poor intake/injection errors/malabsorption/CKD/physical
   - injuries/falls
   - long-term neurocognitive effects
2. Review symptoms
   - neuroglycopenic
   - hypoglycaemic awareness
3. Education
   - involve DNE
   - regular BSL checks 4x/day
   - keeping a diary
   - checking before driving <5
   - overnight BSL
   - hypoglycaemia plan - short acting then long-acting carbohydrates
4. Insulin titration - review doses
5. Continuous glucose monitoring

Question 22

Osteoporosis

Answer 22

1. Address contributing factors/secondary causes
2. Lifestyle - alcohol, smoking cessation, weight-bearing exercise
3. Falls prevention
4. Vitamin D and calcium supplementation
5. Bisphosphonates
6. Denosumab
7. Follow-up

Question 23

Peri-operative management

Answer 23

1. Surgical details - urgency/logistics/risk
2. Peri-operative
   - cardiac - IHD/CCF - stress testing/functional
   - lungs - smoker/COPD
   - endocrine - DM
   - major comorbidities - liver/anaemia
   - obesity/OSA
   - medications
3. Post-operative management
   - functional status
   - psychological and social support systems

Question 24

Incontinence

Answer 24

1. Type of incontinence (stress, urge or mixed)
2. Statement about impact/social/falls risk
3. investigation
   - urine MCS
   - urodynamic studies
4. Non-pharmacological
   - minimize nocturnal fluid intake
   - bladder diary
   - frequent toileting
   - continence aids via a payment scheme
   - manage constipation
   - commodes
   - for stress - pelvic floor exercises
5. Pharmacological
   - oxybutynin for urge
   - mirabegron for urge second line
   - solifenacin for urge incontinence
   - stress - topical oestrogen cream
6. Continence clinic follow-up
7. Surgical management for stress incontinence
8. Whilst I will aim for independent continence, achieving social continence will be a more reasonable and achievable target

Question 25

Malnutrition (assessment)

Answer 25

1. Assess risk and impact of malnutrition
   - reduced intake, recent weight loss, functional impairment, anaemia, hypoalbuminaemia, malabsorption (steatorrhea)
2. Examination findings
   - sarcopenia - function (grip strength, gait speed) and muscle mass (mid arm circumference)
   - micronutrient deficiency (pallor, angular stomatitis, peripheral neuropathy)
   - BMI
3. Tests (characterise malnutrition)
   - FBE, UEC, CMP, LFT, albumin, B12, folate, vitamin D, iron studies, trace elements (zinc, selenium)
   - bone density
   - consider body composition study
4. Tests (for causes of malnutrition)

Question 26

Fatigue (Management)

Answer 26

1. Identify contributing factors (chronic)
2. Additional tests (in addition to causes)
   - anaemia
   - screen for electrolyte disturbances, CKD, CLD
   - TSH
   - iron studies
   - nutritional assessment
   - age appropriate malignancy screening
3. Set goals, manage expectations and follow-up
   - accomplishing activities of daily living (job, ADLs)
4. Non-pharmacological
   - graded exercise program
   - nutrition, weight loss
   - CBT (psychological)
   - support groups
   - sleep hygiene
5. Pharmacological
   - based on cause
   - anti-depressant trial
   - medication review

Question 27

Malnutrition (management)

Answer 27

1. Identify contributing causes
   - chronic pancreatic insufficiency - faecal elastase, AXR
   - review surgical history and length of bowel removed
   - celiac disease - serology + duodenal biopsy
   - terminal ileal resection
   - radiation enteropathy
   - IBD - faecal calprotectin + biopsy
2. Non-pharmacological
   - high energy high protein oral supplementation
   - set targets
   - dietitian input
   - food chart/diary
3. Pharmacological
   - vitamin/micronutrient replacement (injections vs oral)
   - directed to cause
   - total parenteral nutrition
4. Complications of long-term TPN
   - vascular access related issues
   - line sepsis
   - line thrombosis
   - intestinal failure related chronic liver disease
5. Intestinal transplantation
   - reserved for intestinal failure with complications of long-term TPN, poor prognosis

Question 28

Ulcer (aetiology)

Answer 28

1. Infective component
2. Arterial
3. Venous
4. Neuropathic
5. Diabetic
6. Pressure
7. Inflammatory - erythema nodosum/pyoderma gangrenosum
8. Malignancy

Question 29

Ulcer (management)

Answer 29

1. Acknowledge impact on patient
2. Identify contributing factors
   - arterial
   - venous
   - infective
   - peripheral neuropathy
   - pressure
   - diabetic
   - nutritional
   - if ulcer isn’t healing - ?malignancy ?inflammatory - involve dermatology/skin biopsy
3. Treat causes
   - arterial - angioplasty
   - venous - compression/elevation
   - pressure - offload pressure, dressings, wound nurse consultant, GP
   - neuropathy - appropriate footwear, podiatry, foot hygiene
4. Address contributors
   - smoking
   - nutrition
   - infection
   - optimize diabetes
   - prednisolone use
   - poor adherence

Question 30

Cognition

Answer 30

1. Identify Aetiology
   - neurological conditions/dementia
   - structural (SOL)
   - baseline level of education
   - depression
   - comorbidities
   - sleep disorders
   - medication side effects
   - alcohol
2. Assessment
   - Repeat appointment
   - Collateral history
   - Risk assessment
   - MMSE/MOCA
3. Investigations
   - reversible causes screen (nutrition screen, biochemical profile, thyroid function)
   - review imaging - MRI Brain
   - Neuropsychiatric assessment
4. Non-pharmacological
   - education - involve family
   - memory aids - webster packs
   - OT assessment - community supports
   - geriatrician
   - future planning - ACD, place of care
5. Pharmacological

Question 31

Management of central lines

Answer 31

1. Acknowledge need for central line/access
2. Assess adequacy of current line
3. Line sepsis
   - ensure line is only used for chemo/TPN and only by trained personnel
   - review sterile technique
   - general hygiene
4. Thrombosis
   - anticoagulation
5. Future access planning
   - vein mapping
   - Vascular surgeon
6. Consider alternatives to central line