Long Case misc Flashcards
How would you manage falls in the elderly?
- exercise: BALANCE TRAINING
- vitamin D: prevents fractures and falls
- review meds: psychoactives and benzos
- OT home visit
- no bifocals
- cataract surgery
- podiatry/footwear/orthotics
- hip protectors
What are your Dyspnea DDx?
- pulm edema/CCF
- infective
- obstructive lung disease: COPD/asthma
- fibrosis: IPF, interstitial lung disease
- pulm HTN
- haematologic: anemia
What Ix for Dyspnea?
- bloods: FBC, trop, BNP
- ABG
- imaging: CXR, (high res)CT, CTPA, VQ
- spirometry and formal PFT
- PEF
- infective: sputum culture, viral swabs, urine Ag
- bronchoscopy
- biopsy
Prednisone Hx
- why on pred
- duration
- highest, lowest, current dose
- complications
- vaccinations
Prednisone complications Hx
- thin skin/easy bruising
- wt gain, moon face
- DM
- OP: fractures, BMD, OP treatment
- infections
Falls Ix
- ECG/telemetry
- postural BP
- timed up and go text (up, 3m, sit down)
What are some obesity 2’ causes?
Hypothyroidism
Drugs/Meds: prednisone, antidepressants
Cushing’s disease
Hypogonadism
What are non pharm mx of obesity?
Regular clinic follow up Small achievable goals Enlist family help Food diary, exercise diary Dietician Exercise within limits: swimming, aquarobics Very low calorie diet (Optifast)
Indications for bariatric surgery?
- BMI 40+ or BMI 35+ and at least one comorbidity related to obesity (DM, OSA, HTN)
- obese for >5 yrs
- participation in exercise program, motivated
- psychological assessment
- failed previous non Surg therapy
What are some pharmacological Mx for obesity?
- treat underlying depression
- orlistat: 1st line
- if DM, metformin and exanitide
For obesity, explain Optifast diet and some side effects:
1) Intensive phase: 3 Optifast/day + 2cups low starch vegetables
2) Transition: 2 Optifast & 1 meal -> 1 Optifast & 2 meals -> 3 meals
SE: gallstones, muscle cramps, hair loss, fatigue
Obesity, what associated conditions to screen for?
- OA
- OSA
- NASH
- metabolic syndrome: DM, HTN, hyperchol, obesity
- cardiovascular
- skin
- psych: depression, isolation
What are some obesity 2’ causes?
Hypothyroidism
Drugs/Meds: prednisone, antidepressants
Cushing’s disease
Hypogonadism
What are non pharm mx of obesity?
Regular clinic follow up Small achievable goals Enlist family help Food diary, exercise diary Dietician Exercise within limits: swimming, aquarobics Very low calorie diet (Optifast)
Indications for bariatric surgery?
- BMI 35+
- at least one comorbidity related to obesity (DM, OSA, HTN)
- obese for >5 yrs
- participation in exercise program
- psychological assessment
What is the pharmacological Mx for obesity?
- treat underlying depression
- orlistat: 1st line, inhibit fat absorption
- phentermine: SE pulm HTN
- if DM, metformin and exanitide
For obesity, explain Optifast diet and some side effects:
1) Intensive phase: 3 Optifast/day + 2cups low starch vegetables
2) Transition: 2 Optifast & 1 meal -> 1 Optifast & 2 meals -> 3 meals
SE: gallstones, muscle cramps, hair loss, fatigue
Obesity, what associated conditions to screen for?
- OA
- OSA
- NASH
- metabolic syndrome: DM, HTN, hyperchol, obesity
- cardiovascular
- skin
- psych: depression, isolation
What is your general approach to smoking cessation?
- acknowledge difficulty
- set realistic goals
- educate
- enlist family help
- regular follow up
- non pharm and pharm strategies
What are some non pharmacological strategies for smoking cessation?
- manage cravings: gum, keep hands occupied
- avoid high risk situations: post work drinks, etc
- quit line
- support groups
- exercise
What are some PHARMACOLOGICAL strategies for smoking cessation? (And side effects/contraindications)
NRT:
- Start with high dose patches, before bed
- If still smoking, add PRN gum/lozenge/spray
- SE: skin irritation, nausea, nightmares
- CI: pregnancy, within 48hrs of ACS
Varenicline (Champix)
- partial nicotine receptor agonist
Buproprion: (Zyban)
- A Norad/5HT/Dopa reuptake inhibitor
- SE: insomnia, tremor, nausea
- CI: seizures
What are your Ix for osteoporosis?
- EUC/renal function (risk with OP)
- Calcium/Vit D levels
- BMD/DEXA (T score
What are the features of a venous ulcer
- only mild to moderate pain
- shallow with irregular border
- gaiter distribution
- most common cause of LL ulcers
What are the features of an arterial ulcer
- very painful
- distally on toes or on pressure areas, such as heel, malleoli and shin
- punched out lesion/well demarcated edges
What are the features of a neuropathic ulcer
- not painful
- over pressure points on foot or heel
What are the differentials for a lower limb ulcer?
- venous ulcer
- arterial ulcer
- neuropathic ulcer
- skin malignancy: SCC, BCC (Rodent Ulcer)
- vasculitis
- infection
What is your approach to this patient’s alcohol abuse?
Assess impact of EtOH use: - liver/social - comorbidities: anxiety/depression, susbtance abuse Assess motivation/insight: - advise abstinence or cut down Detox - inpatient or outpatient - thiamine replacement - AWS - benzos for DT/withdrawal Prevent relapse: - Naltrexone, acamprosate - disulfiram Harm reduction: - revoke license - DOCS referral
What are the definitions of NYHA classes?
Class 1: No impairment
Class 2: Some impairment with normal activity
Class 3: Severe impairment with minimal exertion
Class 4: SOB at rest
What is your management plan for CCF?
Ix precipitant: non compliance, infection, anaemia, MI
Non pharmacological:
- education
- nutrition/dietician: low Na diet, 1.5L FR
- cardiac rehab: walking, light resistance training
- weight reduction
Pharmacological/Medical Mx:
- ACEi, B-blocker, diuretics/frusemide/spiro
- CRT: if LBBB/QRS>120, EF
How would you investigate HTN?
- ECG: LVH, IHD
- UA: proteinuria, ACR
- CXR
- TTE
2’ causes: renal U/S, 24hr cortisol, metanephrines, sleep study
What are targets for BP control?
Without CVD: BP less than 140/90
If CVD, DM: less than 130/80
How would you manage BP?
Non Pharm: low Na diet, lower etoh, exercise, stop smoking, education
Pharm:
- ACEi, ARB, CCB, or thiazide
What are the targets for cholesterol?
Total cholesterol less than 4
LDL less than 2
TG less than 2
HDL greater than 1
How would you manage hypercholesterolaemia?
- diet
- statins: rosuvastatin is best for avoiding interactions
- ezetemibe if statin CI
- monitor and prevent IHD/PVD/MI/Stroke
What is approach to depression?
1) 4P’s: predisposing, precipitating, perpetuation, protective factors
2) Risk Ax: low/med/high, self/others, intent/plans
3) Management:
Non pharm: exercise, support groups, mood diary
Pharm: 1st line SSRI, 2nd line: escitalopram, add psych input
GP mental health plan
What is your approach to this guy’s non-compliance?
Assess reason: - level of understanding: education - poor motivation: ?depression, social supports - lifestyle - medication factors: pill burden, complexity, cost, access to medications Manage: - apps/reminders - enlist help of carers/family - liaise with GP, pharmacist - Webster pack - positive reinforcement
What is approach to osteoporosis management?
- confirm dx with BMD, assess CMP/vit D levels
- 1st line: Vitamin D replacement, Calcium supplements
- Bisphosphonate: dental review, CI in renal failure
- Denosumab
- Teriparatide for severe OP (PTH analogue)
- Decrease falls risk: vision, medications, OT, walking aids, hip protectors, balance/strength training
What is the ECOG performance status?
- Fully active
- Light work ok
- Self care, but no work; out of bed >50% of day
- Limited self care; in bed >50% of day
- Completely disabled
- Dead
What are the stages to smoking/addiction cessation?
- Pre contemplation
- Contemplation
- Planning
- Action
- Maintenance
