Long Case Issues

Question 1

Immunosuppression: Long term post cyclophosphamide

Answer 1

Total dose of cyclophosphamide, if received mesna
Check if has had eggs harvested, sperm banked
Check Tcell subsets to assess persistent suppression, haematology for lymphopenia
Goal to prevent long term complications of infertility, bladder, haematologic and skin malignancy
Yearly urinalysis and cytology
Urologist for cystoscopy if abnormal,
dermatologist 12 monthly skin screens,
fertility specialist
refer haem early if persistent pancytopaenia
Yearly review of cancer screen

Question 2

A management plan

Answer 2

1. Confirm what’s been told
2. Assess: PEDS – ppt, exclusion, dx, severity
3. Set 3 goals
4. 3 treatment approaches
5. Involve 3 groups: patient, fam, carer, colleagues
6. Prevent/survey for Cx
7. F/up

Question 3

Osteoporosis

Answer 3

Osteoporosis
1. BMD result, FRAX score
2. Secondary screen if Z< -2.0
vit D, myeloma: ESR, SPEP, UPEP, low 24hr urine Ca of FHH
Have to pay for BMD if <70
3. Prevent further fracture and pain
4. Pharmacologic Mx if T<2.5, prev #
a. PMWomen: alendronate all fractures, risedronate vertebral reduce risk by 50%
b. Men: Zoledronic vs denosumab reduce risk vertebral 70%, hip 40%
c. Treat for 10 yrs PO, 6 yrs IV if prev #, reduced hip T score
d. All others 3-5yrs followed by 2-5 yr drug holiday, unless denosumab
5. Adjuncts:
a. oestrogen,
b. fall reduction: balance and resistance exercise
c. calcium in diet, reduce alcohol and smoking
6. Involve specialist in renal impairment, refractory to treatment, atypical femoral fracture
7. Cx: Educate re groin pain of AF, pre tx ONJ risk
8. Follow up 12-24 mth: yearly if T<2.5 and intend to stop tx, 2 yrly if osteopenic

Question 4

Prednisolone

Answer 4

1. implement the recommendations in Considerations throughout immunomodulatory therapy; however, routine blood tests are not recommended with the exception of those needed to monitor the patient’s disease
2. consider hypothalamic–pituitary–adrenal axis suppression (see Glucocorticoid-induced hyperglycaemia)
3. in patients who are predisposed to diabetes or are treated with high doses or prolonged courses of systemic corticosteroids, monitor blood glucose concentrations (see Glucocorticoid-induced hyperglycaemia)
4. use the lowest dose and shortest treatment duration required to achieve disease control
5. monitor and actively manage risk factors for cardiovascular disease, especially with prolonged courses of corticosteroids at daily doses equivalent to 7.5 mg or more of prednis(ol)one (see Cardiovascular disease risk stratification)
6. antimicrobial prophylaxis when planned for treatment with 20 mg or more per day of prednis(ol)one [or equivalent]) for more than 2 weeks. Latent Tb, hep B, strongyloides, listeria precautions, burkholderia if tropics

Question 5

Type 2 Diabetes

Answer 5

Type 2 Diabetes

1. BGL pattern
2. Hba1c
3. Goal
   a. Safety
   b. Minimise complications and acute symptoms
   c. Young, fit and healthy • 6.5-7% • BGLs 4-8, without hypoglycaemia •
   d. Elderly, frail • 8-9% • BGLs 8-12
4. Treatment
   a. Nonpharmacological: cut down discretionary foods, low GI diet, portion control
   b. Exercise: increase step count, graded exercise to target
   c. Monitor BGLs (?CGM) whilst modifying treatment
   i. Insulin pump and private insurance, type 1 only
   ii. MF: renal CI
   iii. SU: wt gain and not for elderly
   iv. DPP4 gliptins: pancreatitis
   v. SGLT2: GUTI, euglycaemic ketoacidosis, stop for OT. CVS and renal benefit.
   vi. GLP1 analogue: suppress appetite, SE n/v, pancreatitis, pancreatic Ca.
   vii. Protophane in prednisolone induced
   d. Licence safety
   e. Involve nephrology, opthal, vascular as needed
   f. follow up monthly in medication changes

Question 6

Obesity

Answer 6

Obesity

1. Confirm and assess complications, contributor: depression, pain
2. Goals: treatment and manage CVS risk
3. Treatment
4. Nonpharmacologic
   a. Diet restriction, low GI foods, portion control, trigger avoidance
   b. Aim 0.5-1kg / week
   c. Exercise
   d. VLED for target purpose: florid T2DM, pre-op
   e. OSA
   f. psychlogy
5. Pharmacotherapy: if can afford offlabel $20/mth topiramate, $200/mth liraglutide, naltrexone/bupropion, cease if weight loss <5% at three to four months.
6. If fails/ severe comorbidities, able to engage and mentally healthy
   a. Bariatric surgery with roux en y (suppresses appetite)
   b. BMI >40, BMI >35lg/m2 with comorbidities.
7. Monitor for cholelithiasis, malnutrition, dehydration
8. F/up monthly and share care with GP, dietitian, psychologist, exercise physio

Question 7

Smoking

Answer 7

Smoking
• Degree of addiction: number of cigarettes, time to smoke (30-60 high risk), Prochaska Diclemente cycle of change: precontemp, contemp, prep, actn, maint, relapse
• Triggers: a quit diary: habits, emotn, social sitch, withdrawal
• Goal: prevent progression COPD, minimise CVS risk, healing etc., prepare for relapse: 80% fail
• Multimodal approach:
• Motivational interviewing
• Diversion activities, involve partner
• Quitline, quit date
• NRT basal and on demand, varenicline/ bupropion NMDA agonist (avoid in seizures)
• Review weekly

Question 8

Alcohol dependence

Answer 8

1. Assess severity: LFT’s, haematology, biochem, ascitic tap, u/s
2. Feedback, individualised about the harms already experienced from alcohol
3. Listen: response and readiness to change, provide info on amt compared to safe levels
4. Advice, clear and non judgemental. Better sleep; more energy • Better physical shape; reduced weight • No hangovers; better memory • Improved mood; fewer family problems • More money • Reduced risk of high blood pressure, liver damage, brain damage, cancer, drink driving, injury to you and others
5. Goals: safety (driving, children) and patients own goals made achievable
6. Strategise: • Drink only with food • Have a glass of water between drinks to quench the thirst • Switch to smaller glass sizes • Switch to low alcohol beer • Avoid going to the pub after work • Avoid or limit time spent with friends who drink heavily • If under pressure to drink, say: ‘My doctor has told me to cut down’ or ‘I’m on a fitness drive’ • Alternatives: – plan other activities or tasks at a time when you usually have a drink – when stressed, take a walk or exercise instead of drinking – explore new interests – spend time with friends who don’t drink

Question 9

CVD

Answer 9

Cardiac disease
• Systolic: idiopath, ETOH, viral, HIV, drugs/radiation, valves, IHD, HTN
• Diastolic: HTN, IHD, HOCM, A/Stenosis
• Ppt: Arrhythmia, Anaemia, Hyperthyroid, sleep apnoea
• Goal: minimise symptoms, reverse neurohormonal remodelling
• Nonpharm: OSA, Na< 2g, EOTH < 1-2std drink, limit fat, vaccine
• Pharm: treat HTN, acei at high risk/ asymptomatic, statin, beta blocker post MI
• Statin post MI
• Beta blocker NYHA class 2-4 symptoms low and slow
• Spiro prolongs survival, reduc morbid, NYHA III-IV, eplero post MI only
• Digoxin improves morbid, use AF, persistent Sx
• Coronary revasc
• LVAD – transplant
• Bivent pace: EF<35%, QRS >120msec, NYHA III-IV
• AICD secondary, primary 40 days post MI E<35% despite optimal Tx