Long Case Flashcards
What investigations should be ordered for resistant hypertension?
electrolytes glucose creatinine urine ACR ambulatory blood pressure monitor screen for primary aldosteronism image for renal artery stenosis sleep study urinary catecholamines investigations for cushing’s
What did the sprint study show?
intensive blood pressure management (SBP 120) had reduced death from any cause compared with standard management (SBP 130-140)
NYHA classes?
NYHA I: no symptoms even during exercise
NYHA II: symptoms with moderate exercise
NYHA III: symptoms with slight exercise
NYHA IV: symptomatic at rest
First line therapy for all heart failure patients?
treat iron deficiency (if ferritin < 100 and tsats < 20%)
lifestyle modification: exercise, weight loss, reduce salt and fluid intake, smoking cessation, reduce EtOH intake
education
avoid exacerbating drugs
manage comorbidities - sleep apnoea, depression
Which heart failure patients qualify for cardiac resynchronisation therapy?
LVEF < 35% and QRS > 150
Which heart failure patients qualify for ICD?
LVEF < 35% and NYHA class II to III
What are the causes of pulmonary hypertension?
pulmonary arterial hypertension due to left heart disease due to lung disease CTEPH unclear
What investigations should be done for pulmonary hypertension?
CXR ECG TTE right heart catheterisation RFTs V/Q scan HRCT sleep study
What management may be beneficial for all types of pulmonary hypertension?
diuretics
oxygen (mortality benefit if group 3)
exercise training
transplantation
What are the lipid targets for IHD?
LDL < 1.8 and TC < 4
Complications of long term steroids?
infections osteoporosis hyperglycaemia skin thinning moon facies buffalo hump ecchymoses obesity cataracts glaucoma fluid retention hypertension premature atherosclerotic disease atrial fibrillation myopathy mood disorders psychosis leukocytosis avascular necrosis
First line investigations for cushings?
late night salivary cortisol
24 hour urinary free cortisol
low dose dexamethasone suppression test
What are the anterior pituitary hormones?
GH FSH LH ACTH TSH prolactin
What is the definition of osteoporosis on T score?
osteopaenia -1 to -2.5
osteoporosis < -2.5
If T score not < -2.5 and no minimal trauma fracture what is the indication for osteoporosis treatment?
using FRAX calculator hip fracture risk > 3% or any fracture > 20%
OR T < -1.5 and on prednisolone > 7.5mg for 3/12
How often should DEXA scans be repeated?
2 yearly once diagnosed
What tests should be done for a secondary osteoporosis screen?
FBE, UEC, SPEP, serum FLCs, UPEP, LFTs, CMP, vitamin D, PTH, TSH, ESR, CRP, testosterone
consider: coeliac antibodies, oestrogen/LH/FSH in women, hypercortisolism screen
What is the MOA of bisphosphonates?
binds hydroxyapeptite in bone and act as osteoclast toxin
Side effects of bisphosphonates?
GI irritation (oral)
flu like symptoms, hypocalcaemia (IV)
atypical femoral fracture
osteonecrosis of the jaw
What is the MOA of denosumab?
antibody that binds RANKL to prevent osteoclast bone resorption
What is the general HbA1c target?
<1%
What did the DAPA-HF study show?
reduced risk of worsening heart failure or death from cardiovascular disease in HFrEF patients regardless of whether they had diabetes
What are the relative contraindications for SGLT2 inhibitors?
general thrush infections, recurrent UTI, ketosis prone, frail elderly, prone to dehydration, immunocompromised, active foot ulcer
When are DPP-4 inhibitors contraindicated?
previous pancreatitis
What are the side effects of GLP1 agonists?
nausea (usually transient), ?pancreatitis, ?neuroendocrine tumours, injection site nodules
To what GFR can SGLT2 inhibitors be used?
according to AMH < 30 as at this level will have reduced glycaemic lowering effect but may still have benefits for CV risk and BP control
What investigations should be ordered in a liver screen?
hepatitis serology (A/B/C) EBV CMV Anti-mitochondrial antibody Anti-smooth muscle antibody Anti-liver/kidney microsomal antibodies Anti-nuclear antibody p-ANCA Alpha-1 Antitrypsin Serum Copper Ceruloplasmin Ferritin
What investigations should be done for coeliac disease?
tTG-IgA (tissue tranglutaminase antibody) + total IgA level
OR
tTG-IgA and DPG-IgG (deamidated gliadin peptide)
What other tests should be done in a new diagnosis of coeliac disease?
DEXA TSH fasting BSL LFTs nutrition assessment: iron, B12, folate, vitamin D, magnesium, zinc
What are the extra intestinal manifestations of IBD?
oral ulcers erythema nodosum large joint arthritis episcleritis primary sclerosing cholangitis ankylosing spondylitis uveitis pyoderma gangrenosum kidney stones, gallstones
Which medications are used for crohn’s?
corticosteroids
thiopurines
methotrexate
biologics
Which biologics are used for crohn’s?
infliximab/adalimumab (anti TNF)
vedolizumab
ustekinumab
What pharmacotherapy options are available for fatty liver disease?
none on PBS
metformin - but doesn’t improve histology
pioglitazone - but risk of weight gain, CCF, osteoporosis
vitamin E - but risk of haemorrhagic stroke
liraglutide
What are the complications of fatty liver disease?
fibrosis cirrhosis HCC CVD (independent risk factor) mortality (all cause)
What are the extra hepatic manifestations of hepatitis C?
membranoproliferative GN porphyria cutanea tarda cryoglobulinaemia lymphoproliferative disorders lichen planus thyroid dysfunction diabetes sjogren’s syndrome polyarthritis
What issues need to be considered for direct acting antiviral therapy for hepatitis C?
genotype presence of cirrhosis concomitant medications/drug interactions (PPIs, statins, amiodarone, anti epileptics) HBV HIV serology eGFR avoidance of pregnancy
What investigations should be done in a patient with chronic hepatitis B?
HBeAg HBV DNA hep A IgG, Hep C Ab, Hep D Ab, HIV LFTs INR AFP liver US fibroscan
Which patients with HCC are eligible for transplant?
a single nodule < 6.5cm or up to 3 nodules the largest of which is < 4.5cm
What is the treatment for PBC?
ursodeoxycholic acid
What is PSC associated with?
UC
What additional treatments are available for UC but not crohns?
5-aminosalicylates
cyclosporin
How often should patients with UC have a colonoscopy to monitor for bowel cancer?
every 3 years after 9 years
What are the treatment related complications of UC?
infections
lymphoma
non melanoma skin cancer (thiopurines)
melanoma (anti TNF)
What are the causes of microcytic anaemia?
iron deficiency thalassaemia anaemia of chronic disease sideroblastic anaemia lead poisoning
What are the causes of normocytic anaemia?
bleeding haemolysis anaemia of chronic disease renal failure bone marrow failure
What are the causes of macrocytic anaemia?
B12 deficiency folate deficiency drugs alcohol chronic liver disease reticulocytosis hypothyroidism MDS
What are the elements of the child pugh score?
encephalopathy INR ascites albumin bilirubin
What diet should chronic liver disease patients be on?
high protein low salt
What are the complications of chronic liver disease?
oesophageal varices ascites +/- SBP hepatic encephalopathy malnutrition sarcopaenia osteoporosis coagulopathy thrombocytopaenia hepatorenal syndrome hepatopulmonary syndrome HCC
When should patients with chronic liver disease have gastroscopy?
screening gastroscopy then annually if small varices and second yearly if no varices
What is the primary prophylaxis for oesophageal varices?
non selective beta blocker or endoscopic band ligation
What is the secondary prophylaxis for oesophageal varices?
variceal banding and non selective beta blocker
What is the pharmacological treatment for ascites?
spironolactone 100mg daily +/- frusemide 20mg daily
max dose spironolactone 400mg daily
How is spontaneous bacterial peritonitis diagnosed?
> 500 leuks or > 250 PMN in ascitic tap
When is primary prophylaxis indicated for SBP?
if low protein < 10g/L or bili >50 with impaired renal function
What are precipitating factors for hepatorenal syndrome?
sepsis/bleeding, acute on chronic liver failure, NSAIDs, paracentesis without albumin replacement, recent TIPS
What is the treatment for hepatorenal syndrome?
avoid nephrotoxic drugs, treat underlying precipitants, withhold diuretics, albumin, terlipressin
What are the precipitants for hepatic encephalopathy?
infection, bleeding, constipation, diarrhoea, metabolic/electrolyte derangement, drugs (opioids, benzos)
What is the treatment for warfarin reversal if life threatening bleeding?
vitamin K infusion
prothrombinex
FFP
What are the common sites affected in graft vs host disease?
skin, GIT, liver, lungs, mucosal surfaces
What is the treatment for graft vs host disease?
steroids
calcineurin inhibitors
What are the complications of multiple myeloma?
hypercalcaemia hyperviscocity spinal cord compression tumour lysis renal disease
What are the complications of thalassaemia?
renal disease due to hyperuricaemia cardiomyopathy due to iron toxicity diabetes due to iron toxicity infections osteoporosis
What are the treatment options for von willebrands disease?
DDAVP during any interventions
TXA
human plasma derived VWF
What is required for a thrombophilia screen?
factor V leiden antiphospholipid antibodies antithrombin protein C, protein S prothrombin gene mutation
What are the complications of CVID?
immune cytopaenia - ITP, AIHA thyroid disease pernicious anemia polyarthropathy polymyositis vitiligo lymphoma gastric cancer amyloidosis impaired lung function/interstitial lung disease/bronchiectasis lymphoproliferation: lymphadenopathy, splenomegaly granulomatous disease
What are the live vaccines?
MMR MMRV oral poliovirus yellow fever varicella HSV rotavirus smallpox adenovirus BCG
What are the major and minor duke criteria for infective endocarditis?
major: positive BC with typical organism in 2 seperate cultures or positive C. burnetii serology evidence of endocardial involvement minor: predisposition fever vascular phenomena immunological phenomena microbiological evidence increased ESR, CRP
What are the indications for valve surgery in infective endocarditis?
IE with signs/symptoms of heart failure paravalvular extension of infection infection with difficult to treat pathogens persistent infections complete heart block \+/- large vegetations (>10mm)
What is the management for CIDP?
steroids steroid sparing agent IVIG PLEX rituximab for nodal disease
What lifestyle advice should be given to patients with seizures?
consider occupational safety
driving - usually need to be 6 months seizure free
good sleep patterns
avoid alcohol
no baths, when having a shower turn cold tap on first
no ladders
medical alert bracelet
What is the McDonalds criteria in MS?
to decide if this is a clinically isolated syndrome vs MS
2 lesions disseminated in time AND space
What tests should be done to exclude MS mimics?
ANA/ENA, vasculitic screen, anti-aquaporin 4 and anti MOG antibodies, syphillis serology
How can you manage bladder dysfunction in MS?
oxybutinin
betmiga
botox
pelvic physiotherapy
How can you manage spasticity in MS?
baclofen
gabapentin
physiotherapy
How can you manage fatigue in MS?
treat concurrent depression review sleep hygiene amantadine modafanil OT assessment
What tests are used to investigate myasthenia gravis?
antibodies - AChR, MuSK
repeated nerve stimulation study
single fibre EMG
CT chest (thymoma)
What are management options for myasthenia gravis?
pyridostigmine (cholinesterase inhibitor) steroids steroid sparing agents IVIG PLEX
What are some “pre symptomatic” signs of parkinsons?
anosmia constipation REM sleep behavioural disorder mood changes increased fatigue/daytime sleepiness urinary symptoms
Which levodopa sparing agents can be used to treat parkinsons?
COMT inhibitors MAO inhibitors dopamine agonists amantadine anticholinergics
What advances therapies are available for parkinsons?
DBS
apomorphine infusion
intraduodenal levodopa
What are the contraindications for DBS in parkinsons?
severe non motor symptoms (dementia), active psychiatric disorders, structural abnormalities on MRI
What investigations should be done for a peripheral neuropathy?
UEC TFT B12, folate HbA1c ESR CRP ANA SPEP nerve conduction studies LP
What are the complications of peritoneal dialysis?
peritonitis
pleuroperitoneal leak
membrane sclerosis
catheter malfunction
What are useful signs of dialysis adequacy?
symptoms
nutritional
fluid balance and blood pressure control
What are the indications for biopsy in IgA nephropathy?
persistent proteinuria > 1g/day
elevated Cr
new onset hypertension or significant elevation from stable baseline
What is the management of IgA nephropathy?
persistent proteinuria (>0.5-1g/day) and normal/slightly reduced GFR:
- ACE inhibitor/ARB
if urinary protein excretion >1g/day continues for 3-6 months after ACE/ARB:
- 6 months of glucocorticoid therapy
rapidly declining eGFR:
- glucocorticoids and cyclophosphamide
What is the general management for nephrotic syndrome?
BP control RAAS blockade treat dyslipidaemia (statin) anticoagulation dietary sodium/fluid restriction diuretics
What is the non pharmacological management for ADPKD?
smoking cessation salt restriction moderate protein intake BMI < 25 increase fluid intake > 3L per day
What is the PBS indication for tolvaptan for ADPKD?
need eGFR < 90 and decline > 5 per year or more than 2.5 per year for 5+ years
What are the targets for renal anaemia?
Hb 100-115
TSAT > 20%
ferritin > 200
What is calcitriol?
The active form of vitamin D
What is cinacalcet?
a calcimimetic - binds to PTH receptors
What does vitamin D do to calcium and phosphate?
increased absorption of both from gut/kidneys
What does PTH do to calcium and phosphate?
increase calcium decrease phosphate
What are the causes of early worsening renal graft function?
graft thrombosis acute rejection CNI toxicity renal artery stenosis obstruction/leak/collection BK nephropathy CMV recurrent disease
What are the risk factors for chronic allograft nephropathy?
prior episodes of acute rejection delayed graft function at transplant HTN excess calcineurin inhibitor inadequate calcineurin inhibitor presence of DSAs
What is the main side effect of valgancyclovir?
neutropaenia
What additional investigations should be done in bronchiectasis?
aspergillus precipitins serum immunoglobulins CF genotype TTE bronchoscopy immune tests including HIV nasal brushings upper GI endoscopy
What is the management for bronchiectasis?
treat the cause smoking cessation vaccination improve airway clearance azithromycin inhaled hypertonic saline treat airway obstruction
What are the elements of the BODE index for COPD?
BMI
obstruction (FEV1)
dyspnoea score
exercise capacity
What did the IMPACT study for COPD show?
in patients with a history of exacerbations triple therapy gave a lower rate of exacerbations/hospitilisations
What are the indications for referral for lung transplantation in IPF?
refer if DLCO < 40, FVC < 80, dyspnoea/functional limitation, SpO2 < 88%
What are the features of obesity hypoventilation syndrome?
awake hypercapnoea
BMI > 30
sleep disordered breathing
What is the diagnostic criteria for OSA?
AHI > 5 + symptoms
AHI > 15 +/- symptoms
What are the complications of OSA?
MVA AF (no effect on mortality) CAD heart failure stroke systemic HTN pulmonary HTN metabolic dysregulation increased all cause mortality CKD GORD NASH
What pharmacotherapy is used for pulmonary arterial hypertension?
calcium channel blockers
endothelin receptor antagonists
PDE5 inhibitors
What are the features of a spondyloarthropathy?
inflammatory back pain sacroilitis enthesitis uveitis dactylitis psoriasis crohn’s/colitis good response to NSAIDs family history HLA-B27 elevated CRP
What are the cardiac and pulmonary extra articular manifestations of spondyloarthropathy?
aortitis aortic regurgitation pericarditis conduction disturbances heart failure IHD stroke VTE pulmonary apical fibrosis (1.3-15%) restrictive lung disease due to diminished chest wall and spinal mobility
What are the complications of ankylosing spondylitis?
osteopaenia/osteoporosis transverse fracture through a fused spine spinal cord injury atlantoaxial subluxation cauda equina symptoms nephropathy
What is the pharmacological management of ankylosing spondylitis?
NSAIDs glucocorticoid injections DMARDs for peripheral arthritis TNF blockers IL-17 blockers
What are the complications of antiphospholipid syndrome?
vascular thrombosis pregnancy complications thrombotic microangiopathic syndromes autoimmune haemolytic anaemia pulmonary hypertension livedo reticularis
What is the management of antiphospholipid syndrome in pregnancy?
positive antibodies only and no clinical manifestations: aspirin during pregnancy
venous/arterial thrombosis: LMWH + aspirin
if recurrent miscarriages: aspirin > add LMWH > add prednisolone
all require LMWH in post partum period
What are the TNF inhibitors?
infliximab
certolizumab
adalimumab
golimumab
What are the contraindications for TNF inhibitors?
previous untreated TB recurrent chest infections/bronchiectasis septic arthritis within 12 months infected prosthesis indwelling IDC MS/demyelinating illness malignancy within 10 years heart failure (NYHA class III-IV) chronic cutaneous ulceration active/chronic infection e.g. osteomyelitis
What are the side effects of methotrexate?
GI upset fatigue mental clouding mouth ulcers hair thinning cytopaenias (monitor FBE) deranged LFTs pneumonitis
What are the side effects of leflunomide?
diarrhoea dry mouth mouth ulcers hair thinning HTN dizziness cytopaenia deranged LFTs pneumonitis peripheral neuropathy shingles
What are the side effects of azathioprine?
bone marrow suppression
hepatitis
fever
increased malignancy (skin - SCC, cervical cancer)
What are the side effects of mycophenolate?
GIT symptoms
cytopaenia (uncommon) - monitor FBE
alopecia
What are the side effects of cyclophosphamide?
bone marrow suppression gonadal suppression alopecia infections GIT effects haemorrhagic cystitis bladder fibrosis bladder ca lymphoma/leukaemia
What tests should be done before starting immunosuppression?
check FBE, UEC, LFTs quantiferon consider CXR HBV and HCV serology HIV varicella
What are the features of dermatomyositis?
symmetrical proximal myopathy heliotrope rash gottron's papules poikiloderma arthirits raynaud's ILD myocarditis associated malignancy
What investigations should be done for dermatomyositis?
CK myositis specific antibodies EMG MRI muscle biopsy TTE RFTs HRCT oesophageal motility studies
What is the target serum urate in gout?
< 0.36 or < 0.30 in tophaceous gout
What is the non pharmacological management of RA?
education smoking cessation maintain active lifestyle physiotherapy occupational therapy
What titre of ANA is significant?
1:320
What are the extra pulmonary sites that can be involved in sarcoidosis?
skin ocular upper respiratory tract cardiac lymph nodes hepatosplenomegaly musculoskeletal neurologic renal
What non blood tests should be done in scleroderma?
barium swallow TTE XR hands HRCT RFTs gastroscopy right heart catheter urinalysis
What is the non pharmacological management for raynaud’s phenonmenon?
keep warm, avoid caffeine, smoking cessation
What is the pharmacological management for raynaud’s phenomenon?
CCB (nifedipine) angiotensin II receptor antagonist PDE5 inhibitors topical or systemic nitrates alpha blockers SSRI antiplatelet/statin IV prostacyclin
What is the pharmacological management of ILD?
mycophenolate 3g/ day
if unresponsive consider cylclophosphamide or azathioprine
What is first line management for scleroderma renal crisis?
captopril
What is the PBS criteria for teriparatide?
“3-2-1” - T score < 3, 2 fractures, at least one fracture while treatment for > 12 months
What investigations should be done for chronic diarrhoea?
iron studies, B12, folate, albumin, FBE, vitamin D, INR, faecal fat estimation, faecal elastase, faecal calprotectin, stool MCS, carbohydrate breath test (SIBO), gastroscopy, colonoscopy, coeliac serology
What are the complications of IBD?
toxic megacolon perforation fistula strictures/obstruction bowel cancer PSC anaemia thromboembolism gallstones/renal stones osteomalacia depression
What investigations should be done for IBD?
stool culture, AXR, FBE, ESR, CRP, faecal calprotectin, LFTs, colonoscopy, mucosal biopsies, antibody testing (ASCA - crohn’s, pANCA - UC), small bowel MRI
What is the management for an acute flare of IBD?
check stool MCS, IV steroids, infliximab, IV abx, surgical mx
How often should screening for HCC be done in chronic liver disease?
6 monthly US and AFP
What are the contraindications for liver transplant?
active sepsis, metastatic malignancy, cholangiocarcinoma, continuing alcohol consumption, advanced cardiopulmonary or renal disease, life limiting co-morbidities, smoking, IVDU
What are the indications for liver transplant?
MELD > 15 HCC sarcopaenia diuretic refractory hepatorenal syndrome refractory hepatic encephalopathy fulminant liver failure
What should you examine for in a patient with falls?
cognitive assessment postural blood pressure romberg's test gait timed up and go parkinsonism visual acuity cerebellar testing peripheral neuropathy
What are management strategies for falls?
review medications correct electrolytes/Hb footwear gait aids strength and balance training vitamin D rehabilitation/physiotherapy home assessment cataract operation education on getting up after a fall personal alarm ix and mx of osteoporosis
What is the usual infection prophylaxis used in bone marrow transplants?
anti fungal - posaconazole, fluconazole - stopped at 2-3 months
PJP - bactrim for 6/12
HSV, VZV - valacivlocir for 1-2 years
CMV - valganciclovir
What vaccinations should HIV patients have had?
hepatitis A/B, meningococcal, pneumococcal, influenza
What regular investigations should HIV patients have?
CD4 count viral load HIV genotype STI tests pap tests (3 yearly) HbA1c, lipids bone mineral density liver function/renal function
What are common side effects of HIV medications?
renal disease, osteoporosis, dyslipidaemia, GI side effects, obesity
What vaccinations are required for splenectomy?
pneumococcus, meningococcus, Hib, influenza
What are the treatment targets for hypertension?
<140/90 is usual target
<130/80 if CKD/T2DM/stroke
What are the contraindications for hydrotherapy?
open wounds, incontinence, severe COPD/heart failure, extreme obesity
What are the side effects of pregabalin?
dizziness, drowsiness, weight gain, peripheral oedema, depression/anxiety
What is the mechanism of action of tapentadol?
opioid agonist and noradrenaline reuptake inhibitor
What are some non pharmacological management options for chronic pain?
pain education resetting expectations CBT referral to chronic pain clinic heat packs TENS physical therapy hydrotherapy
What questions should ask for an obesity history?
timing of weight gain, heighest and lowest weight as an adult, dietary pattern and exercise
What pharmacotherapy can be used in obesity?
GLP-1 agonists, SGLT2 inhibitors, orlistat, phentermine, topiramate
What is an appropriate target for weight loss?
aim reduction of 10% of body weight in 6 months
What is the MOA and CI for phentermine?
MOA: sympathomimetic agent to reduce appetite
CI: severe HTN, CV disease
What is the MOA, SE and CI for orlistat?
MOA: inhibits pancreatic and gastric lipase to reduce fat absorption
SE: steatorrhoea, faecal incontinence, vitamin deficiency
CI: pregnancy
What is the MOA and CI for liraglutide?
MOA: GLP-1 agonist to reduce appetite
CI: severe renal or hepatic disease, phx pancreatitis
What is the main side effect of topiramate and the contraindications?
side effect: cognitive
contrainidcations: glaucoma, renal stones, pregnancy
What are the criteria for bariatric surgery?
BMI > 40 or > 35 with obesity-related contraindication
What should you look for on examination to assess nutrition?
BMI, muscle bulk, pallor, glossitis, angular stomatitis, bruising, peripheral oedema, peripheral neuropathy, bone pain/proximal weakness (vit D)
How should nutritional issues be managed?
investigate for nutritional deficiencies, investigate for reversible contributors (TFTs, endoscopy, malignancy), dietician, optimise other medical conditions, supplementation, MOW, shopping assistance
What are the DSM criteria for depression?
depressed mood anhedonia weight loss or gain insomnia or hypersomnia psychomotor agitation or retardation fatigue worthlessness/guilt decreased concentration suicidal ideation
What is the MOA and CI for varenicline?
MOA: blocks nicotinic AcH receptor
CI: previous SI/psychiatric illness
What is the MOA and CI for bupropion?
MOA: dopamine/NA reuptake inhibitor
CI: seizure disorder
What examination features should you look for in a patient with alcoholism?
wasting jaundice dupuytren's palmar erythema peripheral stigmata of chronic liver disease parotiditis cerebellar/peripheral neuropathy cognitive impairment
What is the MOA, SE and CI for naltrexone?
MOA: opioid antagonist
CIL in liver disease
SE: HA, nausea, dizziness, LFT derangement
What is the MOA and SE for acamprosate?
MOA: GABA agonist to reduce craving
SE: diarrhoea
What is the MOA and CI for disulfiram?
MOA: interferes with breakdown of alcohol
CI: CVD/DM/HTN/CVA
note not on PBS
Template for opening statement
X is a “social statement”. Statement about why they are a long case then in the setting of their other issues. Their main concern is x
Template for closing statement?
adjusted well/poorly, good/guarded prognosis, struggles with…, their health and wellbeing will largely be governed by….
Approach to questions?
why is it important
confirm/establish diagnosis
assess current severity/control
establish usual target/goal +/- modifications for this patient
discuss management options to achieve goal in this patient
discuss follow up
What should you examine for in MS?
spastic paraparesis posterior column sensory loss cerebellar signs cranial nerve examination RAPD
What are the complications of tamoxifen?
VTE
endometrial cancer
hot flushes
cataracts
What are the complications of aromatase inhibitors?
osteoporosis
arthralgia
What are common complications of chemotherapy?
nausea vomiting alopecia cardiotoxicty myelodysplasia peripheral neuropathy
What are the stages of CKD?
1: eGFR > 90
2: eGFR 60-90
3: eGFR 30-59
4: eGFR 15-29
5: eGFR < 15
What is the non pharmacological management of CKD?
fluid restriction salt restriction low protein/potassium diet smoking cessation avoid nephrotoxics
What are the complications of CKD?
HTN renal bone disease renal anaemia hyperkalaemia acidosis fluid overload CVD uraemic pericarditis uraemic encephalopathy
What is required in a transplant workup?
HLA typing DSA typing infections - CMV, EBV, hepatitis, strongyloides, TB skin check FOBT/pap smear/mammogram TTE/stress test
When is home oxygen indicated in COPD?
indicated if PaO2 < 55mmHg
Which COPD patients are a candidate for lung transplant?
only a candidate if < 65, stopped smoking, without other serious comorbidities
What are symptoms of sarcoidosis?
fever, weight loss, LOA, malaise, cough, dyspnoea, erythema nodosum, arthralgia, uveitis, sicca symptoms
What issues should always be considered in a rheumatology case?
disease activity irreversible damage impact on function complications of disease and treatment cardiovascular risk
Which patients with RA qualify for a biologic?
if failed MTX + one other DMARD
Complications of RA?
raynaud’s
sicca symptoms
ILD
CKD (either due to medications or amyloid)
ischaemic heart disease
peripheral neuropathy/mononeuritis multiplex
anaemia of chronic disease
felty’s syndrome - leukopenia + splenomegaly
serositis
What are the elements of the DAS28 score for RA?
tender joint count
swollen joint count
ESR
global health
What are the common symptoms of SLE?
rash, oral ulcer, arthritis, serositis, renal disease, neurological disease, haematological disease, constitutional symptoms
What opportunistic infections should be considered in transplant patients?
PJP, aspergillus, TB, nocardia, CMV, VZV, strongyloides
What are the driving restrictions for syncope?
Unknown cause – conditional license after 6/12 (or 12/12 if 2+ episodes separated by at least 24h)
CV cause – 4 wks
What are the driving restrictions for IHD?
PCI – 2 days
AMI – 2 weeks
CABG – 4 wks
What are the driving restrictions for arrhythmia?
Cardiac arrest – 6/12
ICD insertion – 6/12
PPM insertion – 2 wks
What visual acuity is required to drive?
At least 6/12 vision in one eye
What are the driving restrictions after stroke?
At least 4 weeks
TIA – 2 wks
What are the driving restrictions for epilepsy?
6 months seizure free
