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FRACP Clinical > Long Case misc > Flashcards

Long Case misc Flashcards

1
Q

How would you manage falls in the elderly?

A
  • 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
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2
Q

What are your Dyspnea DDx?

A
  • pulm edema/CCF
  • infective
  • obstructive lung disease: COPD/asthma
  • fibrosis: IPF, interstitial lung disease
  • pulm HTN
  • haematologic: anemia
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3
Q

What Ix for Dyspnea?

A
  • 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
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4
Q

Prednisone Hx

A
  • why on pred
  • duration
  • highest, lowest, current dose
  • complications
  • vaccinations
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5
Q

Prednisone complications Hx

A
  • thin skin/easy bruising
  • wt gain, moon face
  • DM
  • OP: fractures, BMD, OP treatment
  • infections
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6
Q

Falls Ix

A
  • ECG/telemetry
  • postural BP
  • timed up and go text (up, 3m, sit down)
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7
Q

What are some obesity 2’ causes?

A

Hypothyroidism
Drugs/Meds: prednisone, antidepressants
Cushing’s disease
Hypogonadism

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8
Q

What are non pharm mx of obesity?

A 
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)
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9
Q

Indications for bariatric surgery?

A
  • 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
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10
Q

What are some pharmacological Mx for obesity?

A
  • treat underlying depression
  • orlistat: 1st line
  • if DM, metformin and exanitide
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11
Q

For obesity, explain Optifast diet and some side effects:

A

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

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12
Q

Obesity, what associated conditions to screen for?

A
  • OA
  • OSA
  • NASH
  • metabolic syndrome: DM, HTN, hyperchol, obesity
  • cardiovascular
  • skin
  • psych: depression, isolation
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13
Q

What are some obesity 2’ causes?

A

Hypothyroidism
Drugs/Meds: prednisone, antidepressants
Cushing’s disease
Hypogonadism

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14
Q

What are non pharm mx of obesity?

A 
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)
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15
Q

Indications for bariatric surgery?

A
  • BMI 35+
  • at least one comorbidity related to obesity (DM, OSA, HTN)
  • obese for >5 yrs
  • participation in exercise program
  • psychological assessment
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16
Q

What is the pharmacological Mx for obesity?

A
  • treat underlying depression
  • orlistat: 1st line, inhibit fat absorption
  • phentermine: SE pulm HTN
  • if DM, metformin and exanitide
17
Q

For obesity, explain Optifast diet and some side effects:

A

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

18
Q

Obesity, what associated conditions to screen for?

A
  • OA
  • OSA
  • NASH
  • metabolic syndrome: DM, HTN, hyperchol, obesity
  • cardiovascular
  • skin
  • psych: depression, isolation
19
Q

What is your general approach to smoking cessation?

A
  • acknowledge difficulty
  • set realistic goals
  • educate
  • enlist family help
  • regular follow up
  • non pharm and pharm strategies
20
Q

What are some non pharmacological strategies for smoking cessation?

A
  • manage cravings: gum, keep hands occupied
  • avoid high risk situations: post work drinks, etc
  • quit line
  • support groups
  • exercise
21
Q

What are some PHARMACOLOGICAL strategies for smoking cessation? (And side effects/contraindications)

A

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
22
Q

What are your Ix for osteoporosis?

A
  • EUC/renal function (risk with OP)
  • Calcium/Vit D levels
  • BMD/DEXA (T score
23
Q

What are the features of a venous ulcer

A
  • only mild to moderate pain
  • shallow with irregular border
  • gaiter distribution
  • most common cause of LL ulcers
24
Q

What are the features of an arterial ulcer

A
  • very painful
  • distally on toes or on pressure areas, such as heel, malleoli and shin
  • punched out lesion/well demarcated edges
25
Q

What are the features of a neuropathic ulcer

A
  • not painful

- over pressure points on foot or heel

26
Q

What are the differentials for a lower limb ulcer?

A
  • venous ulcer
  • arterial ulcer
  • neuropathic ulcer
  • skin malignancy: SCC, BCC (Rodent Ulcer)
  • vasculitis
  • infection
27
Q

What is your approach to this patient’s alcohol abuse?

A 
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
28
Q

What are the definitions of NYHA classes?

A

Class 1: No impairment
Class 2: Some impairment with normal activity
Class 3: Severe impairment with minimal exertion
Class 4: SOB at rest

29
Q

What is your management plan for CCF?

A

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

30
Q

How would you investigate HTN?

A
  • ECG: LVH, IHD
  • UA: proteinuria, ACR
  • CXR
  • TTE
    2’ causes: renal U/S, 24hr cortisol, metanephrines, sleep study
31
Q

What are targets for BP control?

A

Without CVD: BP less than 140/90

If CVD, DM: less than 130/80

32
Q

How would you manage BP?

A

Non Pharm: low Na diet, lower etoh, exercise, stop smoking, education
Pharm:
- ACEi, ARB, CCB, or thiazide

33
Q

What are the targets for cholesterol?

A

Total cholesterol less than 4
LDL less than 2
TG less than 2
HDL greater than 1

34
Q

How would you manage hypercholesterolaemia?

A
  • diet
  • statins: rosuvastatin is best for avoiding interactions
  • ezetemibe if statin CI
  • monitor and prevent IHD/PVD/MI/Stroke
35
Q

What is approach to depression?

A

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

36
Q

What is your approach to this guy’s non-compliance?

A 
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
37
Q

What is approach to osteoporosis management?

A
  • 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
38
Q

What is the ECOG performance status?

A
  1. Fully active
  2. Light work ok
  3. Self care, but no work; out of bed >50% of day
  4. Limited self care; in bed >50% of day
  5. Completely disabled
  6. Dead
39
Q

What are the stages to smoking/addiction cessation?

A
  1. Pre contemplation
  2. Contemplation
  3. Planning
  4. Action
  5. Maintenance

FRACP Clinical (11 decks)

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