History Conditions Flashcards

Question

Haemophilia

Answer 1

History to include Diagnosis and history: Family History-detailed. Age at diagnosis and how presented. Factor 8 levels; presence of inhibitors Impact on childhood, schooling, sports, dental work. Severity of haemophilia (mild/moderate or severe); are bleeds spontaneous or after minor or major trauma. Number of bleeds per year, where-joints, muscle, internal, external? Management of bleeds: Able to self/family treat or need to admit to hospital. Does the patient have a treatment/management plan  Which replacement product?, Are they adherent to rest/elevation/compression advice? Access to a haemophilia centre. Prophylactic treatment - if so what are they on, how often and how administered? Do they have an inhibitor (if +ve, how has this altered treatment)? e.g. use of emicizumab. Elective surgery, if applicable, management plan. Gene therapy. Complications: Arthropathy-which joints, restriction to ADLs, management to date (multidisciplinary, surgical, pain management etc.) - obesity also a risk factor. Blood borne infection-HIV, HCV, HBV. Chronic pain. Haematuria Genetic counselling / family planning. Psychosocial issues - very important. Monitoring.

Answer 2

HIV Mx in Australasia: History to include Diagnosis, c0-infection and how acquired: How acquired (risk factors), diagnosis & time of diagnosis. Has there been an illness with symptoms suggestive of sero-conversion? Co-infection, e.g., hepatitis. STIs (sexually transmittable infections). Current symptoms/issues Impact of disease/diagnosis on the patient, Current symptoms, Current viral load and CD4 count. Any AIDS defining illnesses: Opportunistic Infections: Pneumocystis jiroveci pneumonia (PJP), Oesophageal candidiasis, MAC, CMV (hepatitis, colitis, retinitis), Toxoplasmosis. Malignancies: Kaposi’s sarcoma. Non-Hodgkin's lymphoma, and cervical malignancies etc. Other: e.g. Progressive multifocal leukoencephalopathy (PML), AIDS dementia. Treatment regimens: Summary of past regimes. Current therapy - note any unusual regimens and/or frequent change in drugs used that may indicate drug-resistance. Side-effects/complications of treatment. Adherence/compliance, insight issues treatment interruptions (very important), aim is for 100% adherence and non-adherence a risk factor for developing drug resistance. Note if patient is n prophylactic therapy e.g. cotrimoxazole that may indicate a low CD4 count. Monitoring - CD4 and viral load counts (at diagnosis, nadir & currently).Discuss in terms of virological and immunological control. Reviews how often and who follows up. Cardiovascular risk factors e.g. dyslipidaemia etc. Future management plans. Social circumstances, supports, any sexual contacts (use of barrier protection, PEP & PrEP).

Answer 3

History to include Diagnosis: What is the condition: ulcerative colitis or Crohn’s disease. Duration of condition, onset of illness and how it was diagnosed. Smoking history. Progression: How has the condition progressed, any hospital admissions? Flare ups, exacerbations: how often & how treated. Current activity - is the condition active or inactive? Symptoms, functional ability: Diarrhoea, how often/much, bleeding, malabsorption (Crohn’s) etc. Fever, fatigue, nutrition, weight, anaemia, fever. In Crohn’s, perianal tags, fisulae, abscesses etc. Extra-intestinal manifestations: Arthritis, peripheral large joints, ankylosing spondylitis, Dermatological, Eyes, Liver - primary sclerosing cholangitis, Increase risk of thrombosis, With the exception of primary sclerosing cholangitis and ankylosing spondylitis, they tend to follow the clinical course of the colitis. Management since diagnosis, medical, surgical, procedural and other. Classify medical therapy as: Treatment of exacerbations/flare, Disease modifying therapy, is the patient on biologics? Side-effects of treatment. Monitoring: Monitoring of disease activity, Side-effects of treatment, Extra-intestinal manifestations, Surveillance for bowel cancer. Psychosocial impact. CVS risk factors.

Answer 4

Diagnosis: Duration of condition, when was diagnosis made., Onset of illness and how it was diagnosed. Investigations - E.g. stress testing, thallium scans and coronary angiography. Progression: How has the condition progressed, any hospital admissions? Flare ups: how often & how treated, Potential exacerbating medical issues such as arrhythmias, anaemia, thyroid disease. What is the current activity, symptoms and functional ability? Management to date & response to various management strategies used: Medical – remember anti-platelet therapy. Any medication contra-indications. E.g. β-blockers and asthma. Procedural. Surgical. Cardiovascular risk factors and their management, list as modifiable and non-modifiable (& know treatment targets). Complications of ischaemic heart disease e.g. heart failure and arrhythmias. Other macrovascular complications e.g. stroke, PVD. Future management plans, monitoring.

Answer 5

Identifying the metabolic syndrome is important because it identifies patients at increased risk of cardiovascular disease, diabetes and chronic kidney disease (2–3 times the risk in that of people without the condition). Mention what criteria are satisfied. There are several diagnostic criteria, below is one example: 3/5 of the following: 1. Increased Central Adiposity / Obesity (depending on sex and ethnicity) – waist circumference > 102cm in men, 88cm in women (European/North American population). 2. Elevated fasting glucose (or drug treatment for elevated glucose) o Fasting blood glucose >6.1mmol/L. 3. Reduced HDL-C (or drug treatment for reduced HDL-C) o < 1.0mmol/L. 4. Raised Triglycerides o >1.7mmol/L. 5. Hypertension o BP ≥130 systolic or ≥85 diastolic . History of obesity (see relevant section in this module). • Complications of obesity, mention in particular: o Obstructive sleep apnoea. o Osteoarthritis. o Falls risk/mobility issues. o Gastro-oesophageal reflux disease. Cardiovascular risk factors and their management (see relevant section of the module). The main purpose of identifying the "metabolic syndrome" is to highlight and manage cardiovascular risk factors. Psycho-social issues.

Answer 6

History of diagnosis: Duration of condition when was diagnosis made? Onset of illness and how it was diagnosed, did the patient present with back pain? Was a bone marrow biopsy performed? Was a skeletal survey performed? Does the patient recall the % of plasma cell and/or abnormal immunoglobulin and its level? Complications: Has myeloma been complicated by: • Anaemia. • Kidney injury. • Hypercalcaemia. • Neurological complications (radiculopathy or spinal cord compression due to plasmacytoma or vertebral fracture. hyperviscosity syndrome, peripheral neuropathy etc.) • Infections secondary to immunodeficiency. Current activity and symptoms • What is the current activity, symptoms and functional ability/QOL (very important)? • Any pain issues? Treatment to-date • If eligible for haemopoietic cell transplantation, then induction therapy, bone marrow transplantation (early or late transplant strategy, autologous or allogeneic etc.). o Post transplant maintenance. • If ineligible for haemopoetic cell transplantation then initial therapy. • Immunosuppression complications. Relapses and their management. Future planning. • If relevant, end of life planning.

Answer 7

Focus on function + ADLS Underlying neurological condition What is the underlying condition?, Duration of condition when was diagnosis made, Onset of illness and how it was diagnosed. How has the condition progressed, any hospital admissions? Flare ups: how often & how are they treated. What is the current activity and what are the current symptoms? Current functional ability (very important) Is the patient independent or dependent in activities of daily living e.g. showering, dressing. Has the patient required home modification? Mobility issues - Does the patient use a gait aid? Are they at risk of falls or have they had falls/near falls. Continence/genito-urinary issues - Bowel regimen, Urinary issues (e.g. self-catheterisation.) Issues with sexual function. Management Medical e.g. steroids, IVIG for CIDP. o In multiple sclerosis consider management of acute flares and disease modifying agents separately. • Occupational therapy e.g. home modification. • Orthotics e.g. footwear, calipers. • Complications of management. • Symptomatic response to management. Complications of condition and their management e.g. falls, foot ulcers in peripheral neuropathy, pneumonia in swallowing difficulties etc. Psychosocial issues. Monitoring - how, how often and by whom?

Answer 8

Definitions: Weight/BMI, waist circumference (central obesity). Normal weight: BMI 18.5 to 24.9. Overweight: BMI 25 to 29.9 Obesity BMI ≥30. Severe obesity - BMI ≥35 (class II obesity). BMI ≥40 (class III obesity, morbid obesity). History of obesity itself: • How long has the patient been overweight/obese – does it date back to childhood/adolescence? Predisposing/exacerbating factors: • Family history. • Mood: depression, mania. • Medications: insulin, antipsychotics (e.g. olanzapine, clozapine), antidepressants, steroids. • Mobility/exercise intolerance. Dietary history: • Does the patient have access to healthy food? • Does the patient consume healthy foods? • Does the patient consume high-energy/fat/carbohydrates foods/soft drinks? • What are the patient’s eating patterns? (regular meals, restriction, snacks, binge eating). • What is the patient’s attitude/insight to dietary behaviour/restrictions? Physical activity: what is the patients level: • Sedentary. • Incidental activity. • Moderate-intense activity (frequency, duration). • Vigorous activity (frequency & duration). • What is the patient’s attitude/insight towards physical activity. Measures to-date in addressing weight: • Dietary: weight-loss and exercise programs, compliance and results. • Involvement of GP, practice nurse, dietician, exercise physiologist and psychologist, other allied health professionals may also be involved (e.g. diabetes educators, mental health nurses, physiotherapists, social workers and occupational therapists). • Suitability for and/or discussion regarding bariatric surgery.

Answer 9

1. Introduction – Introduce self + process, apologise for direct questions Age Recent hospital admissions Brief social setting 2. Medication lists – in body of history Physical exam early (Eg. Obesity, low BMI) 3. Ask patient to list their medical problems 4. Reconcile medications – within list of problems + ensure you can justify all medications 5. Make sure no surprises – ask about mobility, patient’s main concern, what their doctors are concerned about, ask about all symptoms and other medical conditions 6. History of all active problems – inpatient presenting complaint, outpatient – most active issue/symptom Step 7 – Brief Inactive Problems Step 8 – Adherence Issues (if not already mentioned) Step 9 – History of depression: past, current mood Step 10 – Family history- may have already presented eg. IHD/Diabetes/CF Step 11 – Social History, Living arrangements – home modifications, ADLS, supports, finances, social isolation Mobility Alcohol and Smoking Preventative Medicine – vaccines/screening Will/advanced care planning etc.

Answer 10

PRESENTATION 1. Opening Statement 2. Main active problems 3. All the active medical/surgical problems 4. Inactive problems 5. Any medications or allergies not yet mentioned 6. Compliance issues inc. diet 7. Depression 8. Family History 9. Social situation/alcohol/smoking 10. Preventative medicine/vaccine/screening tests 11. Physical examination 12. Summary and Issues

Answer 11

Current Inpatients 1. When admitted 2. Diagnosis/differential diagnosis 3. Presenting symptoms 4. Precipitating factors 5. Risk factors 6. Investigations 7. Treatment and/or changes to usual treatment 8. Complications 9. Current function 10. Plan (for discharge and follow up)

Answer 12

Each Active Condition 1. Duration of symptoms – when was diagnosis made? 2. Onset, symptoms at diagnosis and how the diagnosis was made 3. Aetiology and/or risk factors for the condition 4. A – progression of condition + hospital admissions, B – complications of condition and their management 5. Current symptoms/issues/control of symptoms and underlying disease functional ability 6. Precipitating factors/cause of exacerbations 7. Management – current and in the past, including medical/surgical/procedural Include contra-indications to evidence-based treatments Complications/side effects of the treatment and their management 8. Compliance/insight with: Medications, Diet, Fluid Restriction, Medical appointments etc. 9. Monitoring of the disease and complications of treatment (How, by whom, monitoring of diabetic control and complications) 10. Future management plans – eg. Transplant plans for those on dialysis

Answer 13

Each Active Condition 1. Duration of symptoms – when was diagnosis made? 2. Onset, symptoms at diagnosis and how the diagnosis was made 3. Aetiology and/or risk factors for the condition 4. A – progression of condition + hospital admissions, B – complications of condition and their management 5. Current symptoms/issues/control of symptoms and underlying disease functional ability 6. Precipitating factors/cause of exacerbations 7. Management – current and in the past, including medical/surgical/procedural Include contra-indications to evidence-based treatments Complications/side effects of the treatment and their management 8. Compliance/insight with: Medications, Diet, Fluid Restriction, Medical appointments etc. 9. Monitoring of the disease and complications of treatment (How, by whom, monitoring of diabetic control and complications) 10. Future management plans – eg. Transplant plans for those on dialysis Step 11 – Social History, Living arrangements – home modifications, ADLS, supports, finances, social isolation Mobility Alcohol and Smoking Preventative Medicine – vaccines/screening Will/advanced care planning etc.

Answer 14

Diagnosis PAN – diagnosis + onset Progression – hospital admits? Flare ups – how often and how treated Current activity – symptoms and function Complications of condition and their management • Skin involvement: livedo reticularis, skin ulcers, infarcts, tender erythematous nodules, bullous or vesicular eruption, ulcers palpable purpuric lesions as in other vasculitis. • Raynaud's. • Renal: o Renal insufficiency & hypertension may progress to ESRF/dialysis. • Neurologic disease: mononeuropathy multiplex (or asymmetric polyneuropathy) affecting named nerves (eg, radial, ulnar, peroneal), typically with both motor and sensory deficits, is one of the most common findings in patients with PAN, occurring in up to 60 percent of patients. o Stroke may also occur ?arteritis ?hypertensive. • Gastrointestinal: Mesenteric arteritis causing abdominal pain, bowel infarction. perforation, bleeding etc. hepatic and pancreatic infarction. • Cardiac disease: Myocardial ischaemia, ischaemic cardiomyopathy, remember cardiovascular risk factors. • Muscle: Myalgia. • Other organs maybe affected e.g. eyes, testes ovaries. Management • Management since diagnosis, medical, surgical, procedural etc. • Complications of management. Future plans, monitoring-how, how often and by whom.

Answer 15

Consider: Enjoyment of life. Symptoms – Pain, Energy / Fatigue levels, Sleep, Appetite. Impact of disease - Limitation of activities including housework / ADLs / hobbies (may involve loss of previous role / identity), Ability to maintain family relationships, friendships, engage in community. Burden of Disease - Perceived burden on self / sense of worth, Perceived burden on others (e.g. family / friends). Physical Health Mental Health – Insight, Mood, Motivation.

Answer 16

Diagnosis: Duration of condition, when was diagnosis made., Onset of illness and how it was diagnosed, Patients may know results of rheumatoid factor and/or anti-CCP antibodies. Progression: How has the condition progressed? Flare ups: how often & how treated. Which joints have been affected, in particular ask about hands, shoulders, knees, feet cervical spine etc. What is the impact on function? Mobility, gait aid, need for special utensils, home modifications. Extra-articular manifestations ( lungs, sicca, nodules, pyoderma rash, Felty’s). Current activity, are joints inflamed, swollen, painful, duration of morning stiffness. Management since diagnosis: Medical management. Management of flares, anti-inflammatories, oral steroids and/or intra-articular steroids. Disease modifying agents, e.g. methotrexate, biologics. Surgical management i.e. joint replacement e.g. small joints of the hand, knees. Other, occupational therapy, physiotherapy. Side-effects of steroids & DMARDS, often a significant component of history. Monitoring: How is the patient monitored and followed up. • Monitoring of DMARDS, bDMARD, nbDMARD. Cardiovascular risk factors (autoimmune conditions are an individual risk factor for accelerated atherosclerosis). Impact on quality of life and function.

Answer 17

Diagnosis - Duration of condition, when was diagnosis made. Onset of illness and how it was diagnosed. Was a biopsy taken and if so which organ. Which organs are involved. Possible organ involvement Lung involvement. (Pulmonary fibrosis) Lymphadenopathy. Upper respiratory tract involvement. Skin involvement. Renal involvement. Cardiac - Conduction blocks, Cardiomyopathy. Liver. Central nervous system - Encephalopathy/vasculopathy, Granulomatous meningitis, Peripheral nerve and skeletal muscle involvement. Ocular involvement. How has the condition progressed? e.g. has lung disease progressed. What is the current activity, symptoms and functional impact? How is the condition monitored, how often and by whom? (CXRs, RFTs) What is the management, is the patient on long-term steroids and/or other immunosuppressants?

Answer 18

Remember key points (can change presentation order - link topics together accordingly). A: Accommodation. • Ministry of housing / private renal property / owner-occupied single-storey vs double-storey / residential care (with low or high needs). • Who do they live with at home? Are there carers? A: ADLs, aids. • Current mobility status and exercise tolerance including transfers / stairs. • Personal ADLs: eating / hygiene / dressing / toileting / showering. • Community ADLs: access to community / shopping / banking. • Domestic ADLs: cleaning / cooking / gardening. B: Business, work, occupation. • Retired / aged pension / disability support pension / actively working. • Always ask pre-morbid occupation / gauge education level. C: Coping – links to supports / strategies in place. • Patient and practitioner perspective. D: Driving. • Think about medical / functional restrictions regarding driving (refer to guidelines). E: Exercise, ETOH, smoking, drugs, nutrition. • Quantify, discuss strategies in place. F: Finances. • Pension vs private funds, how has this impacted on disease management and QoL. G: GP and other health specialists, preventative measure (vaccines, screening). H: home help / supports. • Identify key people supporting this patient e.g. immediate family, close friends, what is marital status? • Services in place (link with ‘ADLs’) – can mention what is ideally required. I: Insight. I: Impact. • Disease impact statement – how has the patient’s life changed as a consequence of the illness – e.g. until a few months ago Mr S was independent in his ADLs, he is now requiring the support of his carer etc. J: Judgement. L: Legal. • Will. • Enduring power of attorney. • Advanced care planning.

Answer 19

Diagnosis - Is scleroderma limited or diffuse (determined by involved skin distribution). Duration of condition, when was diagnosis made. Onset of illness and how it was diagnosed. Organ involvement Complications of condition (what organs are involved). Discuss each organ involvement and their management. Organs that may be involved include: Skin involvement, extent (limited or diffuse), restrictions to function, mouth opening. Raynaud’s. • Renal involvement. • Hypertension. • Gastrointestinal/hepatic: o Oesophageal involvement. o Bowel dysmotility. o Hepatic involvement. • Pulmonary: o Fibrosis. o Pulmonary hypertension (NYHA). • Cardiac: o Pericarditis. o Myocarditis. o Cardiac failure. • Musculoskeletal: o Oedema and swelling of the hands, arthralgia and myalgia , a few develop myositis (overlap syndrome). o Contractures & loss of function. o Myopathy. • Neurological: o Cranial nerves, entrapment, peripheral, cutaneous, autonomic neuropathies. o Central nervous system involvement, including headache, seizures, stroke, vascular disease, radiculopathy, and myelopathy. Progression • How has the condition progressed, any hospital admissions? • What is the current activity, symptoms and impact on functional ability? Management • Cover within each organ involvement. Monitoring • Of each organ involved, how, how often and by whom.

Answer 20

History of steroid use: Duration and quantity used including maintenance, maximum doses and how long these were used for. Complications: Cushingnoid appearance, moon face, buffalo hump, central obesity. Skin changes including striae, bruising and healing issues. Bone changes including osteoporosis and avascular necrosis of the head of femur. Bone protection – Calcium; Vit D; bisphosphonate (oral or IV). Other risk factors for osteoporosis. Proximal myopathy. Immune status and infectious episodes. Diabetes. Hypertension. Ophthalmological changes including cataracts, glaucoma. Mood changes and sleep disturbance Patient education particularly in relation to the dangers associated with sudden cessation of steroids. Monitoring-how, how often and by whom.

Answer 21

``` ACR mnemonic of SLE diagnostic criteria "SOAP BRAIN MD" mnemonic: Serositis Oral ulcers Arthritis Photosensitivity Blood disorders Renal involvement Antinuclear antibodies Immunologic phenomena (eg, dsDNA; anti-Smith [Sm] antibodies) Neurologic disorder Malar rash Discoid rash History to cover ``` Diagnosis Duration of condition, when was diagnosis made. Onset of illness and how it was diagnosed. Progression & systems affected How has the condition progressed, any hospital admissions? Flare ups: how often & how treated. Complications of condition and their management. Prioritise systems affected e.g. renal, respiratory, neurological, before joints, skin etc. & address each system as outlined within the module. Current activity and impact What is the current activity, symptoms and impact on the quality of life? Does the patient suffer from a pro-coagulant state? (i.e. lupus anticoagulant, warfarin, pregnancy history). How has the condition affected the patient’s life? (E.g. in female of child bearing years pregnancy issues). Management since diagnosis Address management to organ(s), manifestations of the disease. Note that all patients should be on hydroxychloroquine. Complications of management. Steroid and immune-suppressant side-effects, often a significant component of history. Monitoring of SLE & treatment How is the patient monitored and followed up? Lupus activity and organs involvement e.g. relevant rine and blood tests, respiratory function tests biopsies etc. Monitoring of complications of treatment e.g. eye examination for patients on hydroxychloroquine etc.) Cardiovascular risk factors: Remember cardiovascular risk factors (autoimmune conditions are an individual risk factor for accelerated atherosclerosis).

Answer 22

Brief background Underlying medical condition. Indication for the transplant (very brief). Medical status at the time of transplant? How long was the patient on a waiting list? Special cases In case of renal transplant, was the donor kidney live or cadaveric? In case of cardiac transplant orthotopic (most commonly). In case of lung transplant single or Bilateral Sequential Lung Transplantation. Organ match How well did the organ match? CMV status of both donor and recipient and need for anti-viral (CMV) agents post transplant. Operative complications: Complications or difficulties associated with the transplant procedure (e.g. diaphragmatic paralysis post Lung Tx). Surveillance Monitoring of graft function, how often and by whom, any compliance issues. Rejection, frequency of biopsies & method (e.g. jugular/femoral vein approach in cardiac biopsies and may be complicated by tricuspid regurgitation). Side-effects of immunotherapy e.g. cancer surveillence. Rejection episodes: acute and chronic issues (what are rejection triggers? e.g. infection, compliance, change in immunosuppressants). Immunosuppression issues: Monitoring, how and by whom. General side-effects: episodes of sepsis, & malignancy surveillance/skin protection. More specific side-effects to immune suppressants e.g. G-I symptoms and anaemia (mycophenolate), hirsutism/alopecia, tremor, low magnesium, renal function (CNI), steroid side-effects etc. Potential drug interactions note use of cyclosporine and diltiazem. Prophylaxis, e.g. for PJP. Cardiovascular risk factors maybe relevant in some transplants. Any psychosocial, compliance/adherence issues.

Answer 23

``` • Current Functional Class o NYHA I – Asymptomatic o NYHA II – Dyspnoea with moderate activity o NYHA III – Dyspnoea with mild activity o NYHA IV – Dyspnoea at rest ```

Answer 24

``` Cigarettes - worse due to inflammatory response in HIV, varencicline safe Dyslipidaemia Hypertension - HIV inflammation + ART Female Gender ART - protease inhibitors, atazanavir favourable NNRTs no increased risk NRTI -abacavir increased risk INSTI okay - ?increase metabolic effects ```

Answer 25

HIV-1 virus effects: Adrenalitis (rare), Osteoporosis HIV-related disease - Adrenal : CMV/Toxo, Mycobacteiral, Malignancy Sex hormones - androgen def Immune reconstitution - Addisons - Graves - Hashimotos Drug Effects - Adrenal: Reduce steroid synthesis (ketoconazole) - Thyroid: interferon induced - Diabetes: pentamidine induced def, insulin resistance (protease + NRTIS) - NRTI related OP - Sex hormones: Androgen def

Answer 26

``` Osteoporosis RF: HIV inflammation Medications - all assoc with reduction in BMD, worse with TAF, protease less Tabacco and eTOH Others - osteomalacia and osteonecrosis ```

Answer 27

RF - all - age, HTN, diabetes, obesity, cigarette smoking, co-infection with Hep , APOL-1 risk alleles HIV spec - some ARVS, low CD4+ count, high virla load, hix AIDS -defining illness Transplant in centre with exp good outcomes (but lesst than non HIV)

Answer 28

Tenofovir - renal dysfunction, proximal tubular dysfunction, fanconis Ritonavir/lopinavir - CKD, Riton/darunavir - crystals Cobistat/atazanavir/dolutegravir/rilpirivirne - inhibition of tubular secrection

Answer 29

Tenofovir – renal toxicity TDF – renal + bones (acute = Fanconi’s – RTA, can also get slow decline in eGFR without Fanconi’s) Weight gain, hyperlipids are a concern – more with TAF Abacavir – GIT sx, myalgia, +/- rash, cough, leukopenia, hypersensitivity Doubling of AMI risk in large cohort Covicistat + Dolutegravir impair tubular secretion of Cr (like trimethoprim) CVC risk – protease inhibitors (try not to use) NTD – Dolutegravir – not know significant DHHS still say not a preferred agent WHO now recommends in pregnancy + Dolutegravir + Bictegravir – all <2% Insomnia, headache, dizziness, nausea, diarrhoea Efavirenz – 40% CNS effects- dreams, sleep changes, headaches, rash Teratogenic Lipodystrophy – not so much with newer drugs, older Avoid toxic drugs, treat lipids, DM + Surgery

Answer 30

Screening for and assessment of cognitive impairment in people with HIV infection should be performed if the person is symptomatic (self-reported or family members). This assessment may be difficult in people with co-morbidities that may be responsible for, or contribute to, cognitive impairment, such as cerebrovascular disease, neurodegenerative conditions, HCV co-infection, and mood and sleep disorders. Once mood disorders are either excluded or optimised, and cognitive impairment is suspected, formal assessment by a neuropsychologist or referral to a neurologist is recommended. Ancillary investigations to aid clinical assessment include imaging (MRI brain), blood investigations (i.e. syphilis serology, plasma HIV RNA), and lumbar puncture to investigate for CSF virus escape. Further investigations and functional imaging may take place with specialist referral. If CSF HIV RNA is detected after lumbar puncture, antiretroviral drug resistance testing should be performed to help guide possible change in ART regimen. The optimal ART regimen in the context of suspected or confirmed cognitive impairment is based on best clinical practice, with a regimen that accommodates past and/or present available genotype susceptibility results, and possibly CNS penetrance of the medication. Expert assistance may be required. There is no specific ART regimen that is recommended for people with HIV infection who have cognitive impairment, with the exception of avoidance of efavirenz. Non-pharmacological interventions to consider and encourage include smoking and recreational drug cessation, alcohol reduction, exercise, and healthy eating and sleep hygiene practices.

Answer 31

o For men with score >2 and women with score > 3 – should give oral anticoagulation o For men with score of 1 and women with score of 2 – consider oral anticoagulation o For men with score of 0 and women with score of 1 – anticoagulant therapy is not recommended  Congestive heart failure (+1)  HTN (+1)  Age > 75 (+2)  Diabetes mellitis (+1)  Prev stroke, TIA or thromboembolism (+2)  Vascular disease (+1) • Ie prev MI, peripheral arterial disease or aortic plaque  Age 65-74 (+1)

Answer 32

o For men with score >2 and women with score > 3 – should give oral anticoagulation o For men with score of 1 and women with score of 2 – consider oral anticoagulation o For men with score of 0 and women with score of 1 – anticoagulant therapy is not recommended  Congestive heart failure (+1)  HTN (+1)  Age > 75 (+2)  Diabetes mellitis (+1)  Prev stroke, TIA or thromboembolism (+2)  Vascular disease (+1) • Ie prev MI, peripheral arterial disease or aortic plaque  Age 65-74 (+1)

Answer 33

Diet + Nutrition - salt < 5g/day, protein > 0.75, serum albumin >35 5x week exercise BP <130/80 No etoh/smoking BGLS 6-8 fating, 8-10 post prandial, HbA1c <7%, reduce albuminuria by 50%, lipids - statin in all > 50 or if <50 with IHd/stroke/diabetes Hb 100-115, Ferritin >200, T Sats 2030% once on EPO K <6 Flu and pneumovax Drink to satisfy thirst ACE/ARB, reduction 25% common, avoid NSAIDS triple whammy Education re w/h meds when unwell + reduced PO, W/H ace

Answer 34

CKD-EPI < 60 present for > 3 months OR evidence of kidney dysfunction for > 3 months Also need urine ACR (early morning), USS, repeat bloods + CRP/ESR, lipids + glucose, urine microscopy Ongoing monitoring -a ll above + FBE, CA and phosphate + PTH (6-12 M if EGFR <45)

Answer 35

Every 1-2 years if - diabetes - HTN - CVD - Fam hx - obesity - smoker - ATSI - hx AKI

Answer 36

``` AKI Dialysis Just eaten meat High dietary intake Extremes of body size High muscle mass Children under 18 severe liver disease egFR > 90 Drugs interacting with creatinine (Eg. fenofibrate, trimethoprim) Pregnancy ```

Answer 37

C - need to cut down A - annoyed by suggestion you may have a problem g - guilt about eTOH E - eye opener in morning

Answer 38

``` Duration Onset Progression/flares Current activity/sx and functional status Mx since diangosis Cx Joints involved Extra-articular (lungs/siccs/nodules/pyoderma rash/feltys) Mx -NSAIDs/Pred/DMARDS SE of treatment Pt monitoring + DMARD monitoring CVS Risks (accelerated atherosclerosis) Affect on function Mobility + home mods ```

Answer 39

HOPC - recent assoc problem ie. infection Current status - current treatment + function Prior treatments + complications Don't forgets - Adherence, psychosocial, 'day in the life' Falls and OP CVS Employment/driving

Answer 40

Hydroxychloroquine - monitor for macular changes Sulfasalazine - neutropenia/myelosuppresion/LFTS Methotrexate - myelosuppression, abnormal LFTS, pneumonitis, caution with mouth ulcers Leflunomide - myelosuppression, LFTS, caution with diarrhoea

Answer 41

``` cept = fusion receptor to Fc portion of IgG1 mab = monoclonal Ab ximab = chimeric mAb zumab = humanized Ab tinib = tyrosine kinase inhibitors ```

Answer 42

bDMARDs - TNF (Ra/Psoriatic/AS) Ibfliximab/Adalimumab/Etanercept/Goimumab/Certolizumab/Biosimilars CTLA-4 (RA) - Abatacept AntiCD40 (B cell depletion) - Rituximab Interleukin 6 receptor (RA) - Tozilizumab

Answer 43

JAK inhibitor - tofacitinib (Zelijanz), baricitinib (olumiant), upadacitinib

Answer 44

Infections - TB screen prior, others - don't start, viral hepatitis infection Malignancy - skin checks, stop smoking, and stop if confirmed Injection site/infusion reactions Severe CCF - possible exac with TNF Neurological - TNF C/I in demyelinating (GB/MS/Optic neuritis), - not a C/I rituximab Rituximab- increased risk of PML in patients with SLE + RA Auto-immune like sx - increase antibodies with infliximab, rare SLE drug induced Skin reactions - pustular psoriasis Other- haem transient neutropenia, abnormal LFT ( esp IL-6)

Answer 45

P - recommend cease 3M prior or discontinue if unplanned, breast feeding - mabs okay Vaccination - Small decrease protection with TNF and MTX Lives Vaccines C/I (BCG/Yellow Fever/Herpes Zoster + polio) Surgical - case by case, W/H 2-4 or 4-8 weeks propr.

Answer 46

``` Mx of disease activity Mx of functional status Adherence diet/appointments/DMARDS Pain Mx Falls risk/reduced mobility Increased CVS risk Psychosocial issues ```

Answer 47

``` Mx of SLE Others - organ involved Adherence Issues Psychosocial Cx and monitoring of immune-suppression CVS Risk Factors Bone health - baseline DEXA, Vit D, Dietary Ca, Exercise ```

Answer 48

``` Active Infection (Eg. non curable) Untreatable significant other infection Most malignancies in post 5 years Co-existent bleeding disorder Extrinsic restrictive lung disease (eg. spinal/rib) BMI > 30 Smoking/Drugs/eTOH including nicotine Significant untreatment psychosocial Severely limited functional status Active non adherence ```

Answer 49

``` Low BMI Age > 65 Prior lung surgery Lack of social supports Critical or unstable condition Severe osteoporosis Scleroderma ```

Answer 50

``` Mx of bronchiectasis with aim of optimising resp function Nutrition/BMI/Balancing with diabetic control Others - organ involvement + cx Adherence - diets/apts/lung clerance Gene modular therapy related issues Assessment +/- work up lung tx Psychosocial Fertility ```

Answer 51

Deteriorating graft function Cx and monitoring of immune suppression CVS RF Psychosocial

Answer 52

Progressive pulmonary function impairment - FEV1 < 30% Severe hypoxaemia/hypercarbia Increasing functional impairment Massive life threatening pulmonary complications (Eg. massive haemoptysis)

Answer 53

Clinical - fatigue, alopecia, arthralgias, pleuritic chest pain Lab - reduced complement esp C3 Increased dsDNA, anti c1q (renal lupus) Cytopaenias Features of organ involvement - eg. haematuria

Answer 54

Poor prognostic features: RF +ve, anti-CCP, functional limitation, high number of swollen and tender joint, early erosions, extra-articular features, high ESR or CRP

Answer 55

 Impact: fracture and atherosclerosis  Analysis biochem parameters: aim normal ca/pho and PTH 2-6  Mx: if pho elevated – low pho + dietician (avoid malnutrition), calcium pho binder pre dialysis then change at dialysis. Cholecalciferol if needed, and monitor PTH. Prevent tertiary or adynamic disease

Answer 56

 Okay for eGFR > 30 (ix and treat OP like normal)  Avoid if eGFR < 29 – adynamic disease, denosumab can cause life threatening hypocalcaemia • BUT need to assess EGFR trend  EXCEPT myeloma  Bisphosphonates can also cause AKI: ATN, interstitial nephritis, FSGS

Answer 57

o Investigate anaemia as what we would do and rule out reversible causes  Haematinics – Iron, B12, folate, TFT, EtOH  Myeloma and haemolytic screen  Scope if iron deficient o Manage  Optimize iron – IV – aim for ferritin > 100 and TF Sats 20%  EPO o Target Hb 100-110, Start at Hb < 90, May need to transfuse if more acute, Avoid above 120 due to stroke / fistula thrombosis (okay if natural, not on EPO) – EPO takes 4 weeks to work o EPO Growth factor – caution in solid organ malignancy (depends if curative or not, discuss with pt), DON’T MESSAGE LEVELS Transfusions - ?transplant candidate, ? life threatening

Answer 58

Hyperkalaemia - Acute: Medically or dialysis - Chronic and Prevention: Low K+ diet, Withhold/reduce drugs, Improve glycaemic control, correct acidosis, resonium Fluid Overload – diuretics, fluid restriction, dialysis Acidosis – Consider other causes, Sodium bicarb – 840 – risk of : hypokalaemia/fluid overload, dialysis may be needed Uraemia – acute – pericarditis, encephalopathy (ASAP) Chronic – elective dialysis, itch: emollients, control CKD-MBD Nausea – anti-emetics

Answer 59

Risk factor Die from CVS Elevated phosphate/FGF23 (Don't measure) RF for CVS Proteinuria - RF for CV and ESRF RAS - any (but don't mix), spiro - controversiase, reduce proteinuria

Answer 60

Reducing BP – to reduce risk of CV events, strokes, progression of retinopathy + proteinuria CKD Aims – non proteinuria - <140/90, Proteinuria <130/80, Elderly – individualise (consider 120 with stroke) Lifestyle – Low salt - <2g/day Exercise Weight loss aim BMI 20-25 eTOH – 2/dayM, 1/day F Pharma – ACE/ARB, get BP down with agents

Answer 61

``` Heart disease – anti-anginals/ACE/ARBs/Spirinolactone/Beta blockers/Ca channel blocker Prostatomegaly – Alpha blcoekrs Proteinuria – ACE/Arbs/spirno DM with hypos – AVOID beta blockers Fluid overload- diuretics ```

Answer 62

If 10% risk of CV event in 10 years -> Statin in CKD Anyone above 50 years with any CKD -> 10% CV event within 10 years If less than 50 – any previous CV disease / Stroke / IHD -> statin NO target LDL in CKD, Dialysis can stop if S/Es

Answer 63

- Transplant candidate? o Patient survival - Can they survive the operation? • CRABB, 80% chance of 5 yr survival? Not related to their kidney • Ie another life limiting disease Safe to immunosuppress this patient? - infections Malignancies - within 5 years except skin, RCC local Graft survival - adherence - psychosocial or financial Do they have another active disease that can affect the graft? Anatomically possible? - PVD/Obesity, Space ( PCKD) Immunologically possible - immunomodulation, paired kidney exchange protein, HDx

Answer 64

Induction = high dose steroids + Cyclophosphamide OR mycophenolate (MMF prepared in child bearing age) (6 Months) Lower dose cyclophosphamide was equally as effective + still target MMF non-inferior Maintenance – 2 years of either MMF or AZA (MMF preferred in some trials, AZA in pregnancy)  MMF superior to AZA in trials for maintaining remission If not improved – you try the other agent and then either Rituximab or Calcineurin Inhibitior (refractory = ritux) No evidence for ritux – does work for some people

Answer 65

Withdraw MMF 3-6 M prior HCQ/AZA/PNL/CNI safe Aspirin in active LN (reduce pre-eclampsia) HCQ reduces risk of CHB in anti-RO +Ve

Answer 66

NHL Lung CA Invasive cervical ca Plaquenil reduces malignancy

Answer 67

Steroids work quickly, rapid anti-inflammatory, good for getting disease activity down Never for maintenance: osteoporosis, diabetes, hypertension, obesity, cataracts HLE = best for maintenance Good safety profile, safe in pregnancy Ocular toxicity – review annually after 5 years, risk factors – cumuluative dose (most were on >6.5mg/kg/day long term)

Answer 68

Anti-malarials - skin + joints, chronic therapy Steroids - 0.25mg/kg - skin/joints/MSK Medium - 0.5mg/kg - serosal, moderate haem High - 1mg - CNS/renal /haem Methotrexate- skin + joint disease Aza - 1.5-2.5mg/kg - steroid sparing, GN ober than IV MMF - III - IV Cyclo - severe proliferative GN/ when others fail

Answer 69

CREST – Calcinosis, Raynaud’s, oesophageal dysmotility (can actually be the whole tract), sclerodactyly, telangiectasia (if in mouth can be lower GI tract)

Answer 70

patients with systemic sclerosis (SSc) are treated with organ-based symptomatic therapy. As examples, patients with gastrointestinal reflux are treated with proton-pump inhibitors, patients with Raynaud phenomenon are frequently treated with calcium channel blockers, and patients with hypertensive scleroderma renal crisis are treated with angiotensin-converting enzyme (ACE) inhibitors. Systemic rx (CYC/MMF) - Patients with diffuse skin involvement that is severe or progressive ●Patients with interstitial lung disease ●Patients with myocarditis ●Patients with severe inflammatory myopathy and/or arthritis

Answer 71

``` Clinical - Fatigue/Alopeica Arthralgias/Pleuritic chest pain Lab - Low C3 high dsDNA, anti c1q Cytopenia's Orangs - eg. glomerular hematuria ```

Answer 72

``` Long Term Survival, prevention of organ damage, mx of comorbidities adnd QOLD Adherence Psychosical issues Cx and monitoring CVS RF Bone health ```

Answer 73

<53 (7%) WITHOUT CVS/Long duration/severe hypos < 6.5% Reduced hypo awareness/co-morbidities - 8% Sx control with limited life expectancy 8-15 Planning Pregnancy 6%

Answer 74

``` 1/2, when made RF - fam hx/steroids/pancreatic insufficiency T1DM - Graves/Hashimotos, Coeliac, Addisons Mx - past/present, Diet BGLS HbA1c Hypos + Sx Follow up Macro - IHD/PVD/STroke, additional ```

Answer 75

``` Renal/Diabetic nephropathy- ACEI/ARB, urine ACR, 24 hr collection, RRT? Retinopathy/laser, current acuity Neuropathy (with + without pain) Autonomic dysfunction Postural HTN Gastroparesis Reduce hypo awareness Impotence Angina FOOT CARE - shoes, ulcers, podiatry, amputations, mobility + Falls ```

Answer 76

``` Morning surgery Insulin/dextrose Basal bolus best when eating Frequent BGLS SGLT2 cease 72 hrs prior ```

Answer 77

Clinical status Viral load - should be < 50 CD4 cell count - 3-6 months, usually increases by 100-200 after 12M, can stop > 500 for 6M

Answer 78

FBE/UEC/LFT Urine ACR yearly (if on tDF do phosphate + urine PCR) RF - smoking/diet/exercise/BP and weight Fasting glucose and lipids 6 months after starting therapy, then every 12M Assess risk (FRAX//DEXA) + treat OP Usually Ca screening Vaccinations UTD - flu, HAV/HBV, pneumococcal, HPV, covid