Long Case Flashcards
Parkinson’s Disease
P: TRAP, P+ (PSP, CBD, MSA), LBD
R: Age, FHx, non-creative job, nonsmoking
I: clinical dx. PET, brain imaging to rule out other causes
C: FALLS. fluctuations, dyskinesia, fluctuations and on/off, cognitive impairment, autonomic nervous system
M:
1st - levodopa/benserazide (frequency, long-acting)
2nd - dopamine agonist, MAOi, COMTi
3rd - DBS (only useful if medication working but wearing off ++)
C: mobility, independence, decision making capacity, erectile dysfunction
P: progressive disease, tx symptomatic only
Multiple Sclerosis
P: optic neuritis, INO, cerebellar, UMN weakness
R: caucasian, female, autoimmune
I: McDonald criteria, space and time. MRI: periventricular, juxtacortical, infratentorial, spinal cord
C: FALLS, spasms, urinary retention/incontinence, cognitive, functional decline
M:
Sx - baclofen/dantrolene, catheterization/SPC. Pulsed steroids for acute presentation
1st - interferon, glatiramer (inj) - safe pregnancy
2nd - teriflunomide, DMF, fingolimod
3rd - natalizumab (JC), ocrelizumab (SPMS)
Remember screening for HIV/Hep/TB prior to starting treatment
C: mobility, independence
P: relapsing remitting vs progressive nature
Chronic Kidney Disease
P: fatigue, hypertension, fluid overload, found due to RF
R: T2DM, HTN, recurrent UTI
I:
Dx - ANA, ANCA, C3C4, Hep&cryo, EPP, renal biopsy
Monitor - Cr&eGFR, Hb, PO4&Ca, HbA1c, BP
C: fluid overload, hyperkalaemia, anaemia, CKD-MBD, CVD, dialysis (infection, thrombus)
M:
Prevent: BP/BGL control, treat underlying cause, ACEi for albuminuria, monitor CVD risk factors
CKD: EPO/iron for anaemia; PO4 binders/PTH monitoring; salt/water restriction; low potassium diet,
RRT: organize for access when eGFR <15, US mapping, consider renal transplant
C: adherence, impact of dialysis on activities
P: planned for transplant vs dialysis vs conservative? EOL planning?
Inflammatory Bowel Disease
P: abdominal pain, blood/mucous stools, weight loss, fevers
R: autoimmune, smoking (+crohn, -UC)
I: CRP, calprotectin, faeces PCR, colonoscopy (CRC risk)
C: flare (anaemia, fever, raised CRP, ++bloody stools); megacolon (daily XR), fistulae.
Other systems: joint, back, eye, liver (PSC)
M:
Flare - high dose steroid
1st - mesalazine, sulfasalazine, budesonide foam, enteral diet
2nd - azathioprine, 6MMP (check TPMT levels)
3rd - anti-TNF, anti-IL12/23, colectomy
Fistula - antiTNF, metronidazole
C: impact on work, bowel motions, malnutrition
P: fistulizing complications, biological / surgery considered?
Fibromyalgia
P: fatigue, chronic pain, concentration difficulty, impact on life
R: stress, chronic disease, rheumatoid arthritis
I: exclude other cause (active RF, MSK, anaemia, thyroid etc)
C: Reduced energy and inability to work
M: MDT - education, CBT/anxiety, regular exercise, simple analgesia, pain adjuncts (SSRI / pregabalin)
C: functional capacity
P: chronic and fluctuating, learn to live with condition
SLE
P: SOAP BRAIN MD
R: autoimmune, female, fhx
I: ANA, complement/dsDNA (activity), extended antibody screen (exclude MCTD, SSc, Sjogrens) end-organ (FBC, renal)
C: lupus nephritis, neurological, haematological, joint, CVD
Treatment AE: infection, weight gain, bone health, wound healing, mood
M:
1st - simple analgesia, HCQ, sun protection, CCB raynauds
2nd - steroids for end-organ involvement (AZA or MTX steroid sparing)
- lupus nephritis; mycophenolate treatment of choice
3rd - rituximab
C: social isolation (photosensitivity, cosmetic), joint function, pregnancy implications
P: chronic disease, optimize immunosuppression side effects
Chronic liver disease
P: jaundice, portal HTN (varices, ascites, encephalopathy), fatigue
R: metabolic syndrome, alcohol, IVDU
I: LFTs, synthetic function, liver USS (portal flow, echogenicity), liver screen: hx (alcohol/metabolic), hep/hiv/cmv/ebv, infiltrative (iron, copper, amyloid), autoimmune (SMA, antiLKMA), medication review (DILI)
C: decompensation (variceal bleed, SBP, ascites, encephalopathy); HCC; portal vein thrombus.
M:
Treat underlying cause
Treat decompensation
- Spironolactone/frusemide/low salt high protein diet
- Screen for varices, b-blocker and banding
- Ascitic tap or TIPS if refractory, SBP prophylaxis
- lactulose, rifaximin for encephalopathy
Screen for HCC; resection vs Tx vs RFA vs TACE vs sorafenib
Transplant workup if appropriate
C: insight into disease, stopping drinking, effect on life
P: barriers to transplant? estimated prognosis?
Rheumatoid Arthritis
P: Joint pain and stiffness >1-2hrs, fevers, fatigue
R: autoimmune, female,
I: RF (sens), CCF (spec), exclude seronegatives (PsA, AS)
C: Joint deformity, osteoporosis/osteoarthritis, atlanto-axial dislocation (anaesth), extra-articular (eye, pulmonary, neurological), CV risk
Steroid side effects.
M:
Sx - simple analgesia, NSAIDs. Regular exercise
DMARD
1st - Sulfasalazine, MTX, Aza, HCQ
2nd - biologic (TNFa, IL12/23, rituximab)
Steroids for flare. stop smoking.
C: explore effect of RA on loss of function, FALLS
P: Disease control? consider increasing treatment?
Falls
P: imbalance/visual? external factors? presyncope, weakness, palpitations, LOC? medications
R: sensory impairment, chronic pain or weakness, deconditioning, cardiogenic, autonomic dysfunction, osteoporosis, improper walking aid/footwear, polypharmacy
I: ECG, postural BP, nutrition screen, CT head
C: fracture, fall anxiety –> decreased mobility, further deconditioning.
M: Multidisciplinary falls assessment team
- Medication review (SSRI, sedatives, antiHTN)
- Balance + strength exercise (physio)
- Vit D supplementation
- OT home visit, optimize footwear (podiatry)
- Cataract surgery / optimize eyewear
- bone health
C: fear of falling, social isolation / loss of independence
P: multitargeted management to improve pt’s functionality and reduce risk of future falls
Coeliac Disease
P: weight loss, abdominal pain, fevers/rash
R: autoimmune, female, IgA deficiency
I: IgA(TTG/EMA), IgG (gliadin), HLADQ2 sens, small intestine biopsy while on gluten
C: malabsorption (bone, folate, iron, electrolytes), extra-GI (skin, hyposplenia - vaccination)
M:
- Gluten-free diet (dietician), recheck abs weeks following
- screen other autoimmune (diabetes, thyroid)
- screen bone health, nutrient deficiency
C: ability to adhere to diet - busy job / financial etc.
P: life-long condition, stress importance of gluten free as this can reverse complications
Incontinence
P: stress (musculoskeletal) VS urge (overactivity - parasympathetic) VS overflow (obstruction - sympathetic) VS neurogenic (spinal injury)
R: pregnancy, BPH, recurrent UTI, obesity, spinal cord compression
I: exclude infection (mcs), structural (US KUB). Post-void bladder scan. Consider urodynamic studies if cause is unclear.
C: urinary tract infection - renal impairment, excoriation/rash/cellulitis, social implications
M:
- Cease contributory medications (diuretics, alpha blockers)
- pre-emptive voiding, biofeedback (physio)
- stress: weight loss, pelvic floor surgery/sling
- urge: anticholinergic (oxybutinin) - NB side effects
- overflow: TURP, tamsulosin/prazosin
Refractory: catheter / SPC (risk of infection)
C/P: social embarrassment –> isolation.
Cystic Fibrosis
P: Generally diagnosed at birth screening with sweat test (++Cl). Recurrent respiratory infections, failure to thrive. Malabsorption, small bowel obstruction
R: family (autosomal recessive), Caucasian
I: sweat test, spirometry, immunoglobulins, known colonizers. CXR/CT For focal bronchiectasis. Nutritional screen, liver function. Spirometry to assess degree of lung dysfunction
C: Bronchiectasis, SBO, cirrhosis, Endo/exo pancreatic failure,
M:
Regular sputum clearance and chest physio techniques. Recombinant dornase (mucolytic) Routine vaccination.
Treat other end organ dysfunction
Clear action plan for exacerbation.
Expedited antibiotics for infection. Prophylactic antibiotics (nebs, azithromycin)
C/P: effect on growing up, infertility, shortened life span. Insight and ability to cope with illness. Support group? Candidate for lung transplant? Discussion re ceiling of care.
Multiple Myeloma
P: Calcium, Renal, Anaemia/infection, Bones
R: Age, known MGUS
I: serum EPP, light chains. Bone marrow (>10% plasma cells). X ray showing lytic lesions. Prognostication - albumin + b2 microglobulin. Molecular assays / cytogenetics.
C: CRAB. Renal dysfunction. Hypercalcaemia. Anaemia. Fracture.
Paraproteinaemia - infiltrative disease, autonomic dysfunction and peripheral neuropathy. SOL plasmacytoma
M:
observe if asymptomatic or MGUS
SYMPTOMATIC
- high risk and good candidate; consider autologous HSCT potentially curative
- lower risk / poorer candidate; chemotherapy
– mephalan (not if considered for HSCT)
– thalidomide/lenalidomide (VTE risk)
– proteasome inhibitors bortezomib (peripheral neuropathy)
C/P: discussions re ceiling of care, dialysis requirement. Falls risk!!
