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Long Case subjects > Long case (all subjects RULE OF 5) > Flashcards

Long case (all subjects RULE OF 5) Flashcards

1
Q

Monitoring complications Chronic Liver Disease

A
  1. Varicies
  2. Haematological
  3. Ascites
  4. Nutrition
  5. Malignancy
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2
Q

Management Inflammatory Bowel disease

A
  1. Confirm Dx
  2. Current disease activity
  3. Pharmacological and Surgical treatment options
  4. Nutrition and smoking cessation if (Crohns)
  5. Complications including malignancy risk/extra-intestinal manifestations
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3
Q

Causes of Hepatosplenomegaly

A
  1. Haematological
  2. Viral hepatitis
  3. Chronic liver disease
  4. Connective tissue disorders
  5. Infiltrative disorders
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4
Q

Wound Care

A
  1. Confirm type of ulcer
  2. Address risk factors
  3. Wound care +/- compression
  4. Foot care
  5. Treat infections including OM
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5
Q

Irritable Bowel Syndrome

A
  1. Rule out sinister causes
  2. Reassure Patient
  3. Elimination diet with dietetics
  4. Improve mental health
  5. Pharmacotherapy
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6
Q

Conservative Mngmt severe aortic stenosis

A
  1. Discuss risk/benefits with patient
  2. GDMT but avoid GTN and Beta Blockers
  3. Preventative measures to avoid decompensation i.e. Vaccinations for infection, Rx anaemia, Fluid status reviews
  4. Analgesia (pain & breathlessness)
  5. Palliative care referral
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7
Q

Depression

A
  1. Confirm Dx w SADFACES History
  2. Address precipitating causes (Pain, sleep deprivation, chronic disease, isolation, financial stresses)
  3. Non-pharmacological (exercise, engage family and friends)
  4. MHCP or Psychiatrist referral
  5. Pharmacological
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8
Q

Side effects to monitor with Calcineurin inhibitors

A
  1. Non-melanoma skin Ca
  2. Infection
  3. Nephro & neurotoxicity
  4. Cardiovascular disease risk
  5. Electrolytes
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9
Q

Chronic Pain

A
  1. Confirm causes
  2. Address precipitants for pain (inflammation, degeneration)
  3. Non-pharmacological - social engagement, exercise as tolerated, utilising supports from family/friends
  4. Attempt to use lowest effective dose analgesia - WHO analgesia ladder
  5. Referral to pain service for CBT and Psych
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10
Q

Bleeding on Anticoagulant

A
  1. Weigh up risk:benefit of stopping
  2. Consider reversal agents for severe bleeding i.e. Vitamin K, Idarucizumab, Prothrombin X, Factor replacement
  3. Consider intervention to stop bleeding
  4. Restart within 2 weeks, or 4 weeks if intracerebral bleed
  5. Monitor ongoing bleeding risk
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11
Q

Management of Aortic Stenosis

A
  1. Confirm Dx
  2. Avoid medications that reduce preload
  3. Heart failure GDMT
  4. Consider TAVI vs. surgical AVR
  5. Given option of conservative management
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12
Q

Management of peri-op risk

A
  1. Establish symptoms indicating risk - SOB/angina/OSA
  2. Establish functional status (> 4 mets “metabolic equivalents”)
  3. Discuss surgical risk
  4. Investigate poor functional status i.e. stress echocardiogram
  5. Address risk of post op complications i.e. Delirium
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13
Q

Management of Rheumatic Heart Disease

A
  1. Confirm Dx w Echo
  2. Ensure hx treatment Pt & household contacts
  3. GDMT for HF
  4. Consider valve surgery
  5. Avoid complications - dental hygiene, prophylactic antibiotics for minimum 10 years, covering antibiotics for invasive procedures, vaccinations
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14
Q

Assess activity in IBD

A
  1. Symptoms
  2. Weight/Malnutrition
  3. Inflammatory markers
  4. Ix/evidence of stricturing disease
  5. Extra-intestinal manifestations
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15
Q

Monitoring heart transplant

A
  1. Symptoms
  2. Fluid status
  3. Echo
  4. Angiography
  5. Endomyocardial biopsy
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16
Q

Fitness to drive in Diabetes

A
  1. BSL 5 to drive
  2. 12 monthly driving assessments for IDDM, 5 yearly NIDDM
  3. No severe hypoglycaemia or hypoglycaemic unawareness within 3 months
  4. Annual optical review
  5. Education (Short acting carbs in car, check BSL regularly on long drives)
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16
Q

Fitness to drive in Diabetes

A
  1. BSL 5 to drive
  2. 12 monthly driving assessments for IDDM, 5 yearly NIDDM
  3. No severe hypoglycaemia or hypoglycaemic unawareness within 3 months
  4. Annual optical review
  5. Education (Short acting carbs in car, check BSL regularly on long drives)
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17
Q

Addressing infection risk in immunocompromised Pt

A
  1. Vaccination
  2. Pt education and access to medical care
  3. Good oral and personal hygiene practises
  4. Fix anatomical issues i.e ulcers w poor blood supply, urinary retention
  5. Nutrition optimisation
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18
Q

Assessing frailty

A
  1. Reported exhaustion
  2. Weight loss
  3. slow walking speed (Time to up and go test)
  4. decreased grip strength
  5. Decreased activity
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19
Q

Azathioprine monitoring

A
  1. Malignancy risk
  2. Cytopenias
  3. Infection risk
  4. GI side effects
  5. Drug interactions
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20
Q

Anti-platelet therapy in peri-operative period

A
  1. Confirm indication
  2. Avoid interruption within 3 months of cardiac stenting
  3. Weigh up risk:benefit of interruption
  4. Cease 5-7 days prior to procedure
  5. Restart when surgically appropriate
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21
Q

Optimisation of HF

A
  1. Confirm the diagnosis - NYHA symptoms, HFrEF, HFpEF
  2. Daily weight and Fluid restriction
  3. GDMT w ACEi, SGLT2, Beta Blocker & diuretics
  4. Optimise Cardiac risk factors & nutrition
  5. Advanced therapies such as ARNI, CRT and Tx
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22
Q

Weighing up risk anticoagulation

A
  1. Confirm indication
  2. CHADSVASc (CVD, HTN, Age, DM, Stroke (2), Vasc disease, Sex female)
  3. HASBLED (HTN, Abnormal GFR, Stroke, Bleeding, Labile INR, Elderly, D&E)
  4. Modifiable risk factors i.e. NSAIDs, HTN, Falls risk
  5. Patient education
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23
Q

AF management

A
  1. Confirm Dx
  2. R/O precipitating factors (TFT, OSA, EtOH, structural heart disease)
  3. Rate or Rhythm control
  4. Anticoagulation
  5. Advanced therapies i.e. Ablation and pacing
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24
Q

Obesity Management

A
  1. Ask, Advise, Assess, Assist and Arrange F/U to R/O complications including other CVD risk
  2. Graded exercise program
  3. Caloric restriction
  4. Pharmacotherapy
  5. Bariatric surgery
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25
Q

Management Liver disease

A
  1. Address precipitants (metabolic syndrome, alcohol)
  2. Lactulose, aim 3 stools day
  3. Sprinolactone
  4. High Protein diet
  5. Manage complications including with carvedilol for Varicies
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26
Q

Steroid side effects

A
  1. Immunosuppression
  2. Cardiovascular disease risk
  3. Falls risk w myopathy and cataracts
  4. Mood
  5. Osteoporosis
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27
Q

Management of malnutrition & weight loss with adequate intake

A
  1. Rule out sinister causes (age-appropriate malignancy screen, endcrinopathies, chronic infection)
  2. Food diary
  3. Monitor Malnutrition side-effects
  4. High protein, high caloric diet
  5. Address concurrent depression
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28
Q

Monitoring of Methotrexate (similar for leflunamide)

A
  1. Macrocytic anaemia
  2. Cytopenias
  3. Hepatotoxicity
  4. ILD
  5. Infection risk
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29
Q

Monitoring Pts on Dialysis

A
  1. Adequacy of dialysis with electrolytes, fluid status & calculation Urea reduction ratio
  2. Mineral bone disease with Vitamin D, PO4, PTH levels (3-7 x normal level)
  3. Cardiovascular disease incl. HTN
  4. Anaemia
  5. Mental health
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30
Q

Dietary history

A
  1. Access to food
  2. Storage of food
  3. Composition of diet
  4. Complications of malnutrition
  5. Complications of obesity
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31
Q

Management of frailty

A
  1. Confirm Dx (time to up and go)
  2. Address underlying precipitants (EtOH use, CVD, malignancy, endocrine, medications)
  3. Nutritional optimisation
  4. Weight bearing exercises
  5. Address falls risk
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32
Q

Management of falls risk

A
  1. Identify precipitants (intrinsic or extrinsic)
  2. Balance and weight bearing exercises
  3. OT Ax (home Ax, walking aids, falls alarm)
  4. Medication review for poly pharmacy
  5. Manage complications associated with falls including osteoporosis
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33
Q

Accessing activity of inflammatory arthritis

A
  1. Joint Symptoms
  2. Constitutional symptoms (morning stiffness, fatigue)
  3. Clinical assessment and number of joints (JEBUS - Joint tenderness, Effusions, Bogginess, Ulnar styloid tenderness, Synovitis)
  4. Biochemical assessment (CRP)
  5. Imaging
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34
Q

Management dyslipidaemia

A

1.Confirm Diagnosis
2. Dietary modification - low trans fat diet, salt restriction < 3g/day, avoid EtOH, smoking cessation
3. Exercise
4. Pharmacotherapy
5. Address complications and risk factors

35
Q

Anaemia associated with Dialysis

A
  1. Rule out other causes
  2. Replace iron (Ferritin target 200)
  3. Erythropoetin stimulating agents
  4. Aim Hb < 110
  5. Avoid transfusions if for Tx
36
Q

HTN in CKD

A
  1. Aim BP < 120/80
  2. Lifestyle modifications
  3. ACEi, Ang2i if GFR allows, Diuretics if still producing urine
  4. Ensure adequate dialysis with KT/V (urea reduction ratio)
  5. Address complications of HTN
37
Q

Work-up for Bariatric surgery

A
  1. BMI 35 w complications, 40 w/o complications
  2. Acceptable preoperative risk
  3. Psychological assessment & no substance abuse
  4. Dietetics review and attempt conservative weight loss with opti-fast diet pre-op
  5. Manage patient expectations of weight loss
38
Q

Fatigue assessment

A
  1. Rule out sinister causes
  2. Address sleep hygiene
  3. Address mental health contributions/substance abuse
  4. Medication review
  5. Assess for complications I.e of OSA
39
Q

Management bone marrow transplant

A
  1. Allogenic or autologous +/- pre-Rx conditioning (myeloablation)
  2. Infection risk & post-BMT vaccination
  3. Malignancy risk
  4. Monitor for Sx GVHD
  5. Infertility
40
Q

Monitoring for malignancy after transplant

A

1.Patient education
2. Self skin checks
3. 6 monthly dermatology skin checks
4. Age appropriate malignancy screening
5. Be aware of Post-transplant lymphproliferative disorders

41
Q

Contraindications to transplant

A
  1. Morbid obesity > 40, aim < 30
  2. Active malignancy
  3. Other end organ damage
  4. Severe mental illness, substance abuse, unstable accommodation which may impair compliance
  5. Chronic infection
42
Q

Work-up for nausea

A
  1. History particularly to rule out sinister causes
  2. Medication review
  3. Gastric emptying study
  4. Consider mental health
  5. Reassurance and Pharmacotherapy
43
Q

Work-up for headaches

A
  1. History
  2. Rule out sinister causes & consider brain imaging
  3. Avoid precipitants including EtOH, stresses, sleep deprivation
  4. Pharmacotherapy (triptans, TCA, Topiramate, Propanalol)
  5. Consider LP
44
Q

Perioperative management of Anti-coagulation

A
  1. Confirm indication
  2. Weigh up risk:benefit of interruption
  3. Cease 48-72 hours prior to procedure depending on risk Ax
  4. Bridge with clexane if high risk
  5. Restart when surgically appropriate bridging with clexane until 2 consecutive days of target INR achieved
45
Q

Lack of insight

A
  1. Develop therapeutic relationship
  2. Confirm understanding with gentle disclosure
  3. Engage family members
  4. Addressing any mental health issues or cognitive impairment
  5. Arrange Follow-up
46
Q

Improve adherence

A
  1. Confirm understanding of need for medications
  2. Reduce polypharmacy
  3. Medication reminders and Webster packs
  4. Rule out dysphagia
  5. Engage family members
47
Q

EtOH cessation

A
  1. Ask - CAGE Questioner
  2. Advise importance on physical and mental health
  3. Assess their willingness to quit
  4. Assist - PharmacoRx (diazepam, Methadone), Thiamine, Multivitamin
  5. Arrange F/U +/- inpatient detox
48
Q

Choosing dialysis

A
  1. Discussion with patient w dialysis educator
  2. Peritoneal - increased independence, gentler on haemodynamics, preserves renal function, bad for DM control
  3. Home HD - technically difficult
  4. HD - decreased independence, difficult with brittle haemodynamics
  5. Conservative management or transplant
49
Q

Approach to Renal mineral bone disease

A
  1. Confirm Dx with PTH, calcium and PO4 (aim PTH 3-6 x ULN to avoid dynamic bone disease)
  2. Optimise Vitamin D levels with activated Vitamin D (Calcitriol)
  3. Use phosphate binders
  4. Renal diet
  5. Parathyroidectomy or cinacalcet
50
Q

Preparation for dialysis

A
  1. Begin planning at GFR < 15
  2. Engage dialysis educator
  3. Decide upon type of dilaysis
  4. AVF mapping or tenckoff catheter insertion
  5. Commence based on symptoms, fluid status or electrolyte disturbances
51
Q

Managing Rheumatoid Arthritis

A
  1. NSAIDs and simple analgesia
  2. Exercise as tolerated
  3. Short course of steroids or intraarticuar steroids
  4. Non-biological & DMARDS including MTX (dose increase), anti-TNF, CTLA agonists (decrease intervals)
  5. Address complications including extra-articular manifestations & CVD risk
52
Q

General Immunosuppression monitoring

A
  1. Malignancy
  2. Infection
  3. Drug toxicities
  4. CVD
  5. Haematological
53
Q

Asthma management

A
  1. Confirm the diagnosis and assess for severity
  2. Avoid precipitants i.e. smoking, infections with vaccinations
  3. Asthma management plan
  4. Inhalers - SABA, LABA + inhaled steroids
  5. Biological therapy
54
Q

Management of idiopathic pulmonary fibrosis

A
  1. Confirm Dx w discussion of imaging at a lung MDT
  2. Consider antifibrotic therapy (FVC > 50%, FEV1/FVC > 0.7, DLCO > 30%)
  3. Treat concurrent infections, ensure vaccinations and smoking cessation
  4. Consider home O2 therapy
  5. Palliative care or transplant referral
55
Q

Management of diabetes

A
  1. Monitor control - HbA1c%, fasting and random glucose
  2. Diabetes and diet education
  3. Microvascular, microvascular and infection complications
  4. Pharmacotherapy - OHG, Insulin, GLP1, SGLT2
  5. Devices such as continuous glucose monitor, insulin pumps
56
Q

Management of hyperkalemia in CKD

A
  1. Ensure adequate dialysis via Kt/V
  2. Adherence with renal diet
  3. Medication review - avoid sprinolactone
  4. Correct metabolic acidosis
  5. If not for dialysis, consider resonium
57
Q

Reasons to change ART regime

A
  1. Side effects
  2. Drug-to-drug interactions
  3. Pill burden
  4. Viral Resistance
  5. Access to medication
58
Q

Monitoring & Ix of renal graft function

A
  1. Symptoms and fluid status
  2. Renal function (GFR, electrolytes, proteinuria on urinanalysis)
  3. Consider usual AKI precipitants
  4. Renal biopsy - T or B cell rejection
  5. R/O transplant specific precipitants - Serology for BK virus, JC virus, Tacrolimus levels
59
Q

How to improve glycemic control

A
  1. Confirming control with HbA1c%, fasting and random glucose
  2. Diabetic diet and exercise via DM educator or dietician
  3. Adherence to medications and insulin (including administration, change to long-acting, injection site lipodystrophy)
  4. Medication review ie. steroids
  5. Monitoring with CGM
60
Q

Monitoring of cyclophosphamide

A
  1. Infection
  2. Bladder Malignancy
  3. Haematological malignancy
  4. Infertility
  5. Myelosuppression
61
Q

Interventions for fatigue (non-sinister)

A
  1. Encourage exercise (but not within 6 hours of bed)
  2. Avoid caffeine and stimulants
  3. Avoid increased fluid intake before bed
  4. Treat OSA with CPAP
  5. Address mental health concerns
62
Q

Cystic fibrosis management

A
  1. Education & referral to CF society for psychological supports
  2. Address infection risk - prophylactic Abs, Vaccinations, Treat infections as guided by microbiological sensitivities
  3. Non pharmacological; Regular exercise, chest physiotherapy & nutrition optimisation
  4. Pharmacotherapy, I.e CFTR modulators, DNAse/mucolytics, saline nebulisers, anti-inflammatory macrolides
  5. Advanced options - genetic counselling, IVF for infertility, Transplant, oxygen therapy, Gene therapy
63
Q

Work-up for weight loss with adequate intake

A

If Adequate intake;
1. Age appropriate malignancy screen
2. Thyroid function tests
3. Organ failure - Resp/cardio/Liver/renal
4. Malabsorption - pancreatic, small bowel, large bowel
5. Medication review

64
Q

Work-up for weight loss with inadequate intake

A
  1. Food diary
  2. Consider sinister causes (malignancy, endocrinopathies, chronic disease or chronic infection)
  3. Medication review
  4. Address underlying mental health
  5. Dietetics input for high caloric diet
65
Q

Management of erectile dysfunction

A
  1. Take a sexual history - do they get morning erections? if yes, psychological!
  2. Address any mental health concerns
  3. Optimise CVD and DM management
  4. Medication review
  5. Pharmacotherapy (5 phosphodiesterase inhibitors)
66
Q

Management of Gout

A
  1. Confirm Dx with aspirate
  2. Reduce EtOH, red meat, thiazide diuretics
  3. Treat acute flair with NSAIDs or steroids
  4. Commence prophylaxis after acute flair with NSAID or steroid cover (Allopurinol, Febuxostat, Probenecid)
  5. Aim uric acid < 0.36, or < 0.32 in tophaceous gout
67
Q

Smoking cessation

A
  1. Ask
  2. Advice
  3. Assess
  4. Assist - Quitline, address mental health, engage family & friends, avoid precipitants, pharmacotherapy (dual Rx - NRT, Varenicline (Va-REN-A-Cline), Bupropion)
  5. Arrange F/U
68
Q

COPD management

A
  1. Smoking cessation
  2. Reduce exacerbations - avoid precipitants, vaccinations, macrolide antibiotics
  3. Chest physio, lung boosters, Respiratory rehab program
  4. Pharmacotherapy (SABA, LABA, ICS, LAMA)
  5. Palliative care with home O2 therapy or transplantation
69
Q

Monitoring on DMARDs

A
  1. Disease activity
  2. Infection risk - vaccinations (but avoid live vaccinations)
  3. Myelosuppression
  4. Malignancy - Age appropriate malignancy screening
  5. Infusion reactions
70
Q

Management of hypertension

A
  1. Confirm diagnosis (ambulatory BP monitoring, multiple visits)
  2. Address risk factors - primary or secondary HTN
  3. Non pharmaRx - Low salt diet < 3g/day, smoking cessation, EtOh reduction, Exercise and weight loss
  4. Pharmacotherapy
  5. Address complications
70
Q

Management of hypertension

A
  1. Confirm diagnosis
    -2. Address risk factors - primary or secondary HTN - CVD, Diabetes, Smoking, EtOH
  2. Low salt diet
  3. Exercise and weight loss
  4. Pharmacotherapy
71
Q

Causes of Cardiac graft failure

A
  1. Rejection - early/late, T or B cell
  2. Cardiac vasculopathy
  3. Infection such as CMV
  4. De-innervation arrhythmia
  5. Reoccurrence of underlying pathology
72
Q

Management of ischaemic heart disease

A
  1. Confirm Dx - ECG, stress test (echo, dobutamine, exercise)
  2. Address risk factors
  3. Consider angiogram w PCI
  4. Antiplatelet therapy
  5. CABG
73
Q

Management of OSA

A
  1. History to identify risk factors (i.e. driving)
  2. Encourage weight loss
  3. Avoid EtOH and Benzos
  4. CPAP or BiPAP
  5. Address complications including arrythmias
74
Q

Management of Angina

A
  1. Rest with onset of angina, take 2 GTN sprays and call ambulance; R/O acute MI
  2. Beta blocker therapy & Long acting nitrates
  3. Work-up with EST, Dobutamine ST, Echo
  4. Medical management IHD with DAPT
  5. Angiogram +/- PCI or CABG
75
Q

How to slow progression of CKD

A
  1. Address underlying cause
  2. Manage cardiovascular risk factors (BP aim < 120/80)
  3. Aim proteinuria < 1g/day with ACEi or ARB
  4. SGLT2
  5. Low salt, low protein diet
76
Q

Management of Haemochromatosis

A
  1. Confirm Dx - Fe studies, genetic studies (HFE, C282Y)
  2. Low Iron diet
  3. Phlebotomy
  4. Fe chelation - aim Ferritin < 50
  5. Monitor and asses for complications (Fatigue, HypoPit, Cirrhosis, HCC, DM, Arthritis, CVD)
77
Q

Management of Virological failure on ART

A
  1. Ensure compliance
  2. Ensure no interacting medicatiosn
  3. Genotyping & resistance
  4. Commence alternative ART
  5. Screen contacts
78
Q

Interrupting NOAC for surgery

A
  1. Weigh-up CHADSVASC
  2. Assess surgical risk of bleeding
  3. Consider patients Creatinine
  4. Withhold for 1-3 days prior, dabigatran 1-4 days prior depending on surgical bleeding risk
  5. Restart when clot risk outweighs surgical bleeding risk
79
Q

Management of GVHD

A
  1. Skin -> emollients, topical steroids
  2. Mouth -> dental hygiene, saliva
  3. Eyes -> artificial tears
  4. GIT -> evaluate diarrhoea for c.diff, CMV, scope
  5. Increase or start immunosuppression with Prednisolone and Calcineurin inhibitor
80
Q

Monitoring of Mycophenolate

A
  1. GI upset
  2. Myelosuppression
  3. Infection risk
  4. Consider switching to myfortic
  5. Liver dysfunction
81
Q

Monitoring on mTORi

A
  1. Oedema
  2. Poor wound healing
  3. Nephrotoxicity
  4. Dyslipidaemia
  5. Cytopenias
82
Q

Evaluation of pancreatic insufficiency

A
  1. History including steatorrhoea
  2. Weight diary
  3. Faecal elastase
  4. Fat soluble vitamin levels and replace
  5. Consider cause - CF, Surgical, Chronic pancreatitis
83
Q

CMV status peri-transplant (SOT)

A
  1. D+/R- = Valgancilovir 6 months
  2. D-/R+ = Valganciclovir 3 months
  3. D-/R- = No Valganciclovir
  4. Monitor for CMV colitis
  5. Discuss with transplant team

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