Long case (all subjects RULE OF 5) Flashcards
1
Q
Monitoring complications Chronic Liver Disease
A
- Varicies
- Haematological
- Ascites
- Nutrition
- Malignancy
2
Q
Management Inflammatory Bowel disease
A
- Confirm Dx
- Current disease activity
- Pharmacological and Surgical treatment options
- Nutrition and smoking cessation if (Crohns)
- Complications including malignancy risk/extra-intestinal manifestations
3
Q
Causes of Hepatosplenomegaly
A
- Haematological
- Viral hepatitis
- Chronic liver disease
- Connective tissue disorders
- Infiltrative disorders
4
Q
Wound Care
A
- Confirm type of ulcer
- Address risk factors
- Wound care +/- compression
- Foot care
- Treat infections including OM
5
Q
Irritable Bowel Syndrome
A
- Rule out sinister causes
- Reassure Patient
- Elimination diet with dietetics
- Improve mental health
- Pharmacotherapy
6
Q
Conservative Mngmt severe aortic stenosis
A
- 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
7
Q
Depression
A
- 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
8
Q
Side effects to monitor with Calcineurin inhibitors
A
- Non-melanoma skin Ca
- Infection
- Nephro & neurotoxicity
- Cardiovascular disease risk
- Electrolytes
9
Q
Chronic Pain
A
- 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
10
Q
Bleeding on Anticoagulant
A
- 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
11
Q
Management of Aortic Stenosis
A
- Confirm Dx
- Avoid medications that reduce preload
- Heart failure GDMT
- Consider TAVI vs. surgical AVR
- Given option of conservative management
12
Q
Management of peri-op risk
A
- 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
13
Q
Management of Rheumatic Heart Disease
A
- 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
14
Q
Assess activity in IBD
A
- Symptoms
- Weight/Malnutrition
- Inflammatory markers
- Ix/evidence of stricturing disease
- Extra-intestinal manifestations
15
Q
Monitoring heart transplant
A
- Symptoms
- Fluid status
- Echo
- Angiography
- Endomyocardial biopsy
16
Q
Fitness to drive in Diabetes
A
- 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)
16
Q
Fitness to drive in Diabetes
A
- 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)
17
Q
Addressing infection risk in immunocompromised Pt
A
- 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
18
Q
Assessing frailty
A
- Reported exhaustion
- Weight loss
- slow walking speed (Time to up and go test)
- decreased grip strength
- Decreased activity
19
Q
Azathioprine monitoring
A
- Malignancy risk
- Cytopenias
- Infection risk
- GI side effects
- Drug interactions
20
Q
Anti-platelet therapy in peri-operative period
A
- 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
21
Q
Optimisation of HF
A
- 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
22
Q
Weighing up risk anticoagulation
A
- 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
23
Q
AF management
A
- Confirm Dx
- R/O precipitating factors (TFT, OSA, EtOH, structural heart disease)
- Rate or Rhythm control
- Anticoagulation
- Advanced therapies i.e. Ablation and pacing
24
Obesity Management
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
25
Management Liver disease
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
26
Steroid side effects
1. Immunosuppression
2. Cardiovascular disease risk
3. Falls risk w myopathy and cataracts
4. Mood
5. Osteoporosis
27
Management of malnutrition & weight loss with adequate intake
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
28
Monitoring of Methotrexate (similar for leflunamide)
1. Macrocytic anaemia
2. Cytopenias
3. Hepatotoxicity
4. ILD
5. Infection risk
29
Monitoring Pts on Dialysis
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
30
Dietary history
1. Access to food
2. Storage of food
3. Composition of diet
4. Complications of malnutrition
5. Complications of obesity
31
Management of frailty
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
32
Management of falls risk
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
33
Accessing activity of inflammatory arthritis
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
34
Management dyslipidaemia
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
Anaemia associated with Dialysis
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
HTN in CKD
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
Work-up for Bariatric surgery
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
Fatigue assessment
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
Management bone marrow transplant
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
Monitoring for malignancy after transplant
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
Contraindications to transplant
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
Work-up for nausea
1. History particularly to rule out sinister causes
2. Medication review
3. Gastric emptying study
4. Consider mental health
5. Reassurance and Pharmacotherapy
43
Work-up for headaches
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
Perioperative management of Anti-coagulation
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
Lack of insight
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
Improve adherence
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
EtOH cessation
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
Choosing dialysis
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
Approach to Renal mineral bone disease
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
Preparation for dialysis
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
Managing Rheumatoid Arthritis
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
General Immunosuppression monitoring
1. Malignancy
2. Infection
3. Drug toxicities
4. CVD
5. Haematological
53
Asthma management
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
Management of idiopathic pulmonary fibrosis
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
Management of diabetes
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
Management of hyperkalemia in CKD
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
Reasons to change ART regime
1. Side effects
2. Drug-to-drug interactions
3. Pill burden
4. Viral Resistance
5. Access to medication
58
Monitoring & Ix of renal graft function
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
How to improve glycemic control
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
Monitoring of cyclophosphamide
1. Infection
2. Bladder Malignancy
3. Haematological malignancy
4. Infertility
5. Myelosuppression
61
Interventions for fatigue (non-sinister)
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
Cystic fibrosis management
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
Work-up for weight loss with adequate intake
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
Work-up for weight loss with inadequate intake
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
Management of erectile dysfunction
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
Management of Gout
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
Smoking cessation
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
COPD management
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
Monitoring on DMARDs
1. Disease activity
2. Infection risk - vaccinations (but avoid live vaccinations)
3. Myelosuppression
4. Malignancy - Age appropriate malignancy screening
5. Infusion reactions
70
Management of hypertension
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
Management of hypertension
1. Confirm diagnosis
-2. Address risk factors - primary or secondary HTN - CVD, Diabetes, Smoking, EtOH
3. Low salt diet
4. Exercise and weight loss
5. Pharmacotherapy
71
Causes of Cardiac graft failure
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
Management of ischaemic heart disease
1. Confirm Dx - ECG, stress test (echo, dobutamine, exercise)
2. Address risk factors
3. Consider angiogram w PCI
4. Antiplatelet therapy
5. CABG
73
Management of OSA
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
Management of Angina
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
How to slow progression of CKD
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
Management of Haemochromatosis
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
Management of Virological failure on ART
1. Ensure compliance
2. Ensure no interacting medicatiosn
3. Genotyping & resistance
4. Commence alternative ART
5. Screen contacts
78
Interrupting NOAC for surgery
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
Management of GVHD
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
Monitoring of Mycophenolate
1. GI upset
2. Myelosuppression
3. Infection risk
4. Consider switching to myfortic
5. Liver dysfunction
81
Monitoring on mTORi
1. Oedema
2. Poor wound healing
3. Nephrotoxicity
4. Dyslipidaemia
5. Cytopenias
82
Evaluation of pancreatic insufficiency
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
CMV status peri-transplant (SOT)
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
