Long case (all subjects RULE OF 5) Flashcards
Monitoring complications Chronic Liver Disease
- Varicies
- Haematological
- Ascites
- Nutrition
- Malignancy
Management Inflammatory Bowel disease
- Confirm Dx
- Current disease activity
- Pharmacological and Surgical treatment options
- Nutrition and smoking cessation if (Crohns)
- Complications including malignancy risk/extra-intestinal manifestations
Causes of Hepatosplenomegaly
- Haematological
- Viral hepatitis
- Chronic liver disease
- Connective tissue disorders
- Infiltrative disorders
Wound Care
- Confirm type of ulcer
- Address risk factors
- Wound care +/- compression
- Foot care
- Treat infections including OM
Irritable Bowel Syndrome
- Rule out sinister causes
- Reassure Patient
- Elimination diet with dietetics
- Improve mental health
- Pharmacotherapy
Conservative Mngmt severe aortic stenosis
- Discuss risk/benefits with patient
- GDMT but avoid GTN and Beta Blockers
- Preventative measures to avoid decompensation i.e. Vaccinations for infection, Rx anaemia, Fluid status reviews
- Analgesia (pain & breathlessness)
- Palliative care referral
Depression
- Confirm Dx w SADFACES History
- Address precipitating causes (Pain, sleep deprivation, chronic disease, isolation, financial stresses)
- Non-pharmacological (exercise, engage family and friends)
- MHCP or Psychiatrist referral
- Pharmacological
Side effects to monitor with Calcineurin inhibitors
- Non-melanoma skin Ca
- Infection
- Nephro & neurotoxicity
- Cardiovascular disease risk
- Electrolytes
Chronic Pain
- Confirm causes
- Address precipitants for pain (inflammation, degeneration)
- Non-pharmacological - social engagement, exercise as tolerated, utilising supports from family/friends
- Attempt to use lowest effective dose analgesia - WHO analgesia ladder
- Referral to pain service for CBT and Psych
Bleeding on Anticoagulant
- Weigh up risk:benefit of stopping
- Consider reversal agents for severe bleeding i.e. Vitamin K, Idarucizumab, Prothrombin X, Factor replacement
- Consider intervention to stop bleeding
- Restart within 2 weeks, or 4 weeks if intracerebral bleed
- Monitor ongoing bleeding risk
Management of Aortic Stenosis
- Confirm Dx
- Avoid medications that reduce preload
- Heart failure GDMT
- Consider TAVI vs. surgical AVR
- Given option of conservative management
Management of peri-op risk
- Establish symptoms indicating risk - SOB/angina/OSA
- Establish functional status (> 4 mets “metabolic equivalents”)
- Discuss surgical risk
- Investigate poor functional status i.e. stress echocardiogram
- Address risk of post op complications i.e. Delirium
Management of Rheumatic Heart Disease
- Confirm Dx w Echo
- Ensure hx treatment Pt & household contacts
- GDMT for HF
- Consider valve surgery
- Avoid complications - dental hygiene, prophylactic antibiotics for minimum 10 years, covering antibiotics for invasive procedures, vaccinations
Assess activity in IBD
- Symptoms
- Weight/Malnutrition
- Inflammatory markers
- Ix/evidence of stricturing disease
- Extra-intestinal manifestations
Monitoring heart transplant
- Symptoms
- Fluid status
- Echo
- Angiography
- Endomyocardial biopsy
Fitness to drive in Diabetes
- BSL 5 to drive
- 12 monthly driving assessments for IDDM, 5 yearly NIDDM
- No severe hypoglycaemia or hypoglycaemic unawareness within 3 months
- Annual optical review
- Education (Short acting carbs in car, check BSL regularly on long drives)
Fitness to drive in Diabetes
- BSL 5 to drive
- 12 monthly driving assessments for IDDM, 5 yearly NIDDM
- No severe hypoglycaemia or hypoglycaemic unawareness within 3 months
- Annual optical review
- Education (Short acting carbs in car, check BSL regularly on long drives)
Addressing infection risk in immunocompromised Pt
- Vaccination
- Pt education and access to medical care
- Good oral and personal hygiene practises
- Fix anatomical issues i.e ulcers w poor blood supply, urinary retention
- Nutrition optimisation
Assessing frailty
- Reported exhaustion
- Weight loss
- slow walking speed (Time to up and go test)
- decreased grip strength
- Decreased activity
Azathioprine monitoring
- Malignancy risk
- Cytopenias
- Infection risk
- GI side effects
- Drug interactions
Anti-platelet therapy in peri-operative period
- Confirm indication
- Avoid interruption within 3 months of cardiac stenting
- Weigh up risk:benefit of interruption
- Cease 5-7 days prior to procedure
- Restart when surgically appropriate
Optimisation of HF
- Confirm the diagnosis - NYHA symptoms, HFrEF, HFpEF
- Daily weight and Fluid restriction
- GDMT w ACEi, SGLT2, Beta Blocker & diuretics
- Optimise Cardiac risk factors & nutrition
- Advanced therapies such as ARNI, CRT and Tx
Weighing up risk anticoagulation
- Confirm indication
- CHADSVASc (CVD, HTN, Age, DM, Stroke (2), Vasc disease, Sex female)
- HASBLED (HTN, Abnormal GFR, Stroke, Bleeding, Labile INR, Elderly, D&E)
- Modifiable risk factors i.e. NSAIDs, HTN, Falls risk
- Patient education
AF management
- Confirm Dx
- R/O precipitating factors (TFT, OSA, EtOH, structural heart disease)
- Rate or Rhythm control
- Anticoagulation
- Advanced therapies i.e. Ablation and pacing
Obesity Management
- Ask, Advise, Assess, Assist and Arrange F/U to R/O complications including other CVD risk
- Graded exercise program
- Caloric restriction
- Pharmacotherapy
- Bariatric surgery
Management Liver disease
- Address precipitants (metabolic syndrome, alcohol)
- Lactulose, aim 3 stools day
- Sprinolactone
- High Protein diet
- Manage complications including with carvedilol for Varicies
Steroid side effects
- Immunosuppression
- Cardiovascular disease risk
- Falls risk w myopathy and cataracts
- Mood
- Osteoporosis
Management of malnutrition & weight loss with adequate intake
- Rule out sinister causes (age-appropriate malignancy screen, endcrinopathies, chronic infection)
- Food diary
- Monitor Malnutrition side-effects
- High protein, high caloric diet
- Address concurrent depression
Monitoring of Methotrexate (similar for leflunamide)
- Macrocytic anaemia
- Cytopenias
- Hepatotoxicity
- ILD
- Infection risk
Monitoring Pts on Dialysis
- Adequacy of dialysis with electrolytes, fluid status & calculation Urea reduction ratio
- Mineral bone disease with Vitamin D, PO4, PTH levels (3-7 x normal level)
- Cardiovascular disease incl. HTN
- Anaemia
- Mental health
Dietary history
- Access to food
- Storage of food
- Composition of diet
- Complications of malnutrition
- Complications of obesity
Management of frailty
- Confirm Dx (time to up and go)
- Address underlying precipitants (EtOH use, CVD, malignancy, endocrine, medications)
- Nutritional optimisation
- Weight bearing exercises
- Address falls risk
Management of falls risk
- Identify precipitants (intrinsic or extrinsic)
- Balance and weight bearing exercises
- OT Ax (home Ax, walking aids, falls alarm)
- Medication review for poly pharmacy
- Manage complications associated with falls including osteoporosis
Accessing activity of inflammatory arthritis
- Joint Symptoms
- Constitutional symptoms (morning stiffness, fatigue)
- Clinical assessment and number of joints (JEBUS - Joint tenderness, Effusions, Bogginess, Ulnar styloid tenderness, Synovitis)
- Biochemical assessment (CRP)
- Imaging