Long case spiels Flashcards
Heart failure/Cardiomyopathy
Differentials: Idiopathic Ischemic Hypertension Valve related Myocarditis Alcohol Rate related Takusubo Post partum Haemochromatosis/amyloidosis/sarcoidosis Endocrinopathies: Hyperthyroidism/acromegaly HCM/ARVC
Investigations:
CXR - pumonary odema, cardiomegaly
ECG - arrythmias, q-waves to suggest previous ischemia
ECHO - LV function, regional wall motion abnormalites, valve disease
ETT/ESE/Angiogram - to exclude ischemia
Bloods - renal, liver, iron studies, TFTs, anaemia, SFLC
Cardiac MRI
Endomyocardial biopsy
Management: Non-pharmacological - education - daily weights (greater than 2kgs over target weight, should prompt action) - fluid restriction in severe CHF less than 1.5L - low salt diet - heart failure nurse - cardiac rehabilitation - avoid alcohol - smoking cessation - vaccinations - driving (no driving with ICD or symptomatic CHF) - advanced care planning Pharmacological - diuretics - loop and thiazides (symptoms only) - ACE-I (survival) - B-blockers (survival) - Aldosterone antagonist (survival) - Digoxin (controversial, increase in mortality) - Long acting nitrates (symptoms) - Others - Ivabradine, angiotensin neprilisn inhibiton Devices - CRT (survival) - ICD (survival benefit) Surgery - heart transplant
Parkinson’s disease
Key features:
Motor: Tremor, akinesia, rigidity, postural instability
Non-motor: cognitive dysfunction and dementia, psychosis and hallucinations, mood disorders, sleep disorders, autonomic dysfunction (postural hypotension/constipation/sexual dysfunction/urinary incontinence)
Differentials: Idiopathic parkinson's disease Dementia with lewy bodies Atypical parkinsons syndromes (PSP, MSA, corticobasal degeneration) Drug induced Normal pressure hydrocephalus Wilson's disease (young patients) Vascular parkinsons
Investigations:
Clinical diagnosis
Confirmed with response to levodopa therapy
MRI can exclude other causes
Management:
Non-pharmacological
- education
- support groups
- physiotherapy
- speech and language therapist
- dietitian
- social worker (carer stress)
- occupational therapy
- cognitive behavioural therapy/counselling
- orthostatic advice
- increase fluid and fibre intake (constipation)
- asessment of cognition
- advanced care planning
Pharmacological
- laxatives
- consider cholinesterase inhibitor for cognitive impairment
- psychosis - only evidence is for Clozapine but quetiapine can be used (others make much worse)
- Levodopa combined with peripheral decarboxylase inhibitor = best therapy
- Dopamine agonists (risk of impulse control disorder)
- Mao-B inhibitors, anticholinergics, amantadine, COMT inhibitors
Surgery
- deep brain stimulation (subthalamic nucleus/globus pallidus)
Monitor for on/off phenomenon and dyskinesias
- best treatment is to fractionate L-dopa - give low doses more frequently
- add COMT inhibitor (entacapone etc.)
- DBS early
Cognitive impairment
Differentials: Delirium (illness, drugs, alcohol withdrawal etc.) Mild cognitive impairment Alzheimer Vascular Lewy body demenita Frontotemporal Normal pressure hydrocephalus Depression
Investigations:
Remember clock drawing and AMT in long case
Collateral history
Review medication chart
Bloods: electrolyte derangement, inflammatory markers, B12/folate, TFTs
Urinalysis, bowel chart
CT head: vascular change, NPH
Geriatric depression scale
MOCA/ACE-III
Functional assessment (important in distinguishing from MCI and dementia)
Management: Non pharmacological - Involve family and main supports - EPOA - Education - Consider safety, communication, environment - Manage pain - Assess hearing and vision - Support groups e.g Alzheimer society - Dietitian - high risk of malnutrition - SLT - dysphagia - Social worker - supports, respite, carer stress - OT and PT - advanced care planning - sleep hygiene
Pharmacological
- treat precipitating causes (infections, remove offending drugs)
- consider cholinesterase inhibitor (except for in Frontotemporal dementia)
- anti psychotics for management of aggression/behaviours (try to avoid if possible due to increased stroke risk)
- treat depression with SSRI’s
Palliative management in end stage disease
Diabetes
Investigations: BSLs HBA1c Blood pressure, lipids Results of retinal screening Urine protein creat ratio Creatinine
Management: Type 1 - education - medical alert bracelet - driving - employer supportive? - diabetes nurse - BSL testing at least 4x a day - insulin therapy (usually basal bolus) - role of carbohydrate counting, insulin sensitivy factor and insulin pumps - unwell advice - take insulin, liquid glucose, test for ketones, present early for medical attention - hypoglycemic education - exercise (reduce insulin or supplement with glucose) - regular assessment for complications (see below) - smoking cessation - limit ETOH - pregnancy planning - mental health - screen for other autoimmune disorders - perioperative management
Type 2
- education
- weight loss
- diabetes nurse
- testing and control
- diet advice/alcohol/smoking
- diet controlled, metformin, sulphonylurea, insulin
- newer GLP-1 analogues, DPPIV inhibitors
- statin
- aspirin controversial (can be considered in those with more than one risk factor)
Complications
Microvascular
- nephropathy
- 3 monthly PCR and creat
- blood pressure control (goal less than 130/80) ACE-I
- assess for dialysis or transplant
- PD better for diabetics
- retinopathy
- opthalmology every 2 years
- panphotocoagulation vs avastin
- peripheral neuropathy
- annual review with monofilament
- inspect feet daily
- 4 monthly podiatry
- careful nail care
- footwear
- early medical assessment of skin ulcers
- autonomic neuropathy
- orthostatic advice
- screen for erectile dysfunction
Macrovascular
- PVD/CVA/CVD
Targets:
HbA1c less than 53 indicates good control
Less than 40 in a patient on insulin indicates likely hypoglycemic episodes
ACCORD trial showed increase mortality in elderly with tight control
Maintaining independance
PT - structured excercise programme to maintain strength and balance, walking aids
OT - vocational OT, equipment around the house
Driving assessments
SW - assessments for supports
Driving support agencies - driving miss daisy
Maintain good relationship with GP, possibility of home visits
Support groups - information sharing
Engaging family
Stop smoking and reduce alcohol
Screening for depression
Blisterpack for medications
Osteoporosis
History of fractures and pain
Consider secondary causes: steroids, hypogonadism, thyroid disease, chronic heparin treatment, drugs (lithium, enzyme inducing anti-convulsants) malabsorbtion, malnutrition, connective tissue disease
Investigations
Bloods: ALP, Calcium, Vit D, PTH
DEXA scan - T score less than 2.5
Management: Smoking cessation Alcohol reduction Excercise - weight bearing excercise Calcium - ideally 2 servings of calcium per day Vit D Bisphosphonates Other option: Teriparatide (T score less than -3), Denosumab, Raloxefine
COPD
Non-pharmacological
- education
- written action plan
- nutrition
- smoking cessation
- vaccination (flu vaccine - annually, pneumovax 5 yearly)
- pulmonary rehab (education/optimising medical management, PT, psychosocial support)
- flying advice
- home oxygen (paO2 less than 55, or less than 60 with pul hypertension)
- home BiPap
- lung volume reduction surgery
- lung transplantation
- advanced care planning/hospice/palliative care
Pharmacological
- no evidence for prophylaxic antibiotics
- some role for macrolide as anti-inflammatory
- Step 1: Short acting bronchodilator (b-agonist, anticholinergic)
- Step 2: Add long acting bronchodilator (b-agonist, anticholinergic)
- Step 3: Add inhaled glucocorticoid (indicated for severe COPD with exacerbations)
- Consider adding tiotropium for severe COPD
Treat exacerbations - steroids, oral antibiotics, NIV
Things that improve survival: smoking cessation and oxygen Things that improve QOL: pulmonary rehab - also reduces hospitalisations Things that reduce exacerbations: inhaled corticosteroids LABAs
Falls
Education - home - footwear - alcohol use - diet Consider TaiChi for balance MDT - rehabilitation - OT: environment, free from clutter, rails, ramp, lighting - PT: transfers, education around excercise daily - SW: home alarm, medicalert bracelet Medically - Vision - Hearing - Continence - Hip protectors - Osteoporosis - Vit D, bisphosphonate - Postural hypotension - Medication review (greater than 4 medications = bad)
Long-term corticosteroid use
side effects: MANY!!! immunosuppression adrenal suppression Cushing's syndrome hyperglycaemia and diabetes cardiovascular disease fluid retention osteoporosis (>5mg/day associated with sig reduction in BMD) osteonecrosis cataracts and glaucoma psychiatric disturbance GI bleeding myopathy impaired wound healing
corticosteroids have both glucocorticoid and mineralocorticoid effect:
glucocorticoid - anti-inflammatory, immunosuppression, vasoconstrictive effects
mineralocorticoid - electrolyte and fluid balance
prior to starting long-term steroids
- lowest dose for shortest time
- consider steroid sparing agents where possible
- assess for infection e.g. active shingles, Hepatitis, TB
- assess BMD (DEXA) then 1 year F/U then 2-3 yearly
- assess baseline cardiovascular risk including lipids, HbA1c
adrenals:
- screen for adrenal suppression with early morning cortisol if suspected, if low performed short synacthen (insulin tolerance test is definitive test)
eyes:
annual ophthalmology review if > 6/12 treatment
bones (see osteoporosis speil)
greatest bone loss in first 6-12 months of treatment
adequate dietary calcium intake
Vit D supplementation
all patients on >7.5mg/day of Pred for > 3/12 are at risk
in general those > 65 should be on bisphosphonate
also consider if 15 - insulin
* adjust diabetes medications and increase BSL monitoring if steroid dose changed
GI:
consider PPI for GI protection
Education:
- increase dose when unwell
- don’t stop suddenly
- inform medical professionals of long-term steroid use
- medic-alert bracelet
- symptoms of development of hyperglycaemia
- test BSLs more freq and contact GP/practice nurse if change in dose if diabetic
Lifestyle:
- regular exercise, limit sugar in diet - to prevent excessive weight gain
Transplant
Pre-transplant:
- underlying disease
- function prior to transplant (ie. hospital admissions, requirement for home O2, LVAD, dialysis)
- work up for transplant (cardiovascular, respiratory, CMV, Tb etc.)
Transplant:
- Type of donor (live, deceased, related, unrelated)
- Match of donor
- CMV status
- immediate operative and post operative complications
- Duration since transplant
Post transplant:
- immunosuppression
- prophylaxis (viral/bacterial/fungal)
- ongoing screening (diabetes, hypertension, skin cancers, other malignancies)
- monitoring of graft function
- episodes of rejection
- monitoring for disease recurrence
- current graft function
- social impact of transplant (e.g displacement from home)
- follow up at transplant unit
- understanding of survival of graft
Immunosuppression:
- interactions
- drug monitoring (levels, side effects)
- infective complications
- importance of compliance
Splenectomy
Either elective splenectomy, emergency splenectomy or hyposplenic due to underlying disease (e.g. coeliac disease)
Vaccination pre-splenectomy (or 2 weeks after emergency procedure):
2 weeks before
- meningicoccal
- pneumococcal
- Hib
- influenza
Splenectomy patients are able to have live vaccines
Management post-splenectomy:
- notify all medical practitoners about hyposplenism
- medic-alert bracelet
- seek medical attention early if unwell
- liaise with primary care practitioner with clear instructions for maintenance of vaccinations
- give supply of amoxicillin to take if unwell and unable to immediately access medical care
- daily antibiotics for first 2 years (at least) after splenectomy (highest risk period) - amoxicillin or penicillin V
- avoid travelling to countries with malaria
- advise of high risk of infection after animal bites
- carry splenectomy card with you at all times
Follow up vaccines:
Meningococcal - every 5 years
Pneumococcal - every 5 years
Yearly influenza vaccine
Cirrhosis
Compensated cirrhosis
- asymptomatic, no varices/ascites
- median survival greater than 12 y
Decompensated cirrhosis
- symptomatic
- development of jaundice, ascites, variceal haemorrhage or hepatic encephalopathy
- 1 year survival 61%
Management and monitoring of complications
General:
- vaccinations
- abstinence
- avoid hepatotoxins
- weight loss
- screen for HCC every 6 months with USS
Ascites (1 y survival = 50%)
- SAAG greater than 11 = due to portal hypertension
- salt restriction
- diuretics; spironolactone better than frusemide
- large volume paracentesis
Varices (mortality 20% with each bleed)
- endoscopy at diagnosis of cirrhosis
- no varices = repeat 2-3 y intervals
- varices = risk assessment; small + red wale mark or large (greater than 5mm), then prophylaxis
- primary prophylaxis: non selective beta blocker or endoscopic variceal ligation
- secondary prophylaxis (prev haemorrhage): both non selective beta blocker + endoscopic variceal ligation
- acute bleeding: non aggressive resus, terlipressin, antibiotics, endoscopic banding, balloon tamponade, TIPS (transjugular intrahepatic portosystemic shunt)
Spontaneous bacterial peritonitis (mortality 20% with each episode)
- ascitic tap = PMN greater than 250, positive micro
- ceftriaxone
- recur in 70%; prophylaxis with norfloxacin
Hepatorenal syndrome
- type 1 = acute onset with associated drop in BP, poor prognosis (median survival 2 weeks)
- type 2 = slow progression of renal impairment (6 month survival)
- consider terlipression
- dialysis as bridge to transplant
Hepatic encephalopathy (1 y survival 40%)
- treat precipitant: infection, bleeding, constipation, diarrhoea, drugs, metabolic derangement
- lactulose
- rifaximin
- do not protein restrict (increases mortality)
Chronic kidney disease
General management
- avoid nephrotoxins
- target BP 130/80 or 125/75 if proteinuria
- ACE-I or ARB for proteinuria
- lifestyle modifications: alcohol, smoking, exercise
- control glucose (target HbA1c less than 53)
- reduce drug doses as appropriate
- monitor GFR 3 monthly
Complications
- fluid overload: need higher doses of diuretics
- hyperkalaemia: low K diet, avoid drugs (NSAIDs)
- CVD: leading cause of mortality
- anaemia (seen in Stage 3-4 CKD, typically less than 30ml/min); consider EPO if Hb less than 100, must be iron replete (ferritin greater than 200), consider inflammation, hyperparathyroidism, aim Hb 100-120
- haemostasis: DDAVP, cryoprecipitate, blood tx
- uraemic peripheral neuropathy
- Ca/PO4: dietary PO4 restriction, phosphate binders (calcium containing if hypocalcaemia), activated Vitamin D, consider cinacalcet and parathyroidectomy
- calciphylaxis: wound care, high dose oxygen, sodium thiosulphate with dialysis, increased time on haemodialysis, stop warfarin and iron
Non-pharamacological
- diet: get a dietician involved
- low sodium and K+ diet
- fluid restriction
Common drug interactions to remember in transplant patients
Drugs for infection:
Azole antifungals - inhibit CYP3A4 = increase CNI levels
Macrolides (except Azithromycin) also inhibit CYP3A4
Rifampicin induces 3A4 = lower drug levels
Hypertension:
Non-dihydropyridine calcium channel blockers (Diltiazem/Verapamil) inhibit 3A4 = increase CNI levels (can be used as a CNI sparing agent)
Antidepressants:
SSRIs have mild inhibiton of 3A4 - Sertraline and Ecitalopram considered best of antidepressants
Statin:
Metabolised through CYP3A4, CNIs inhibit this and risk of developing statin myopathy and liver failure
- use pravastatin (low potency steroid and monitor LFTs and CK)
Alcohol
Guidelines
Women - no more than 10 drinks per week, no more than 2 drinks per day
Men - no more than 15 drinks per week, no more than 3 every per day
2 alcohol free days per week
CAGE questions:
Are you Concerned about your drinking?
Do you get Angry if anyone criticizes your drinking?
Do you feel Guilty about drinking?
Do you need an drink early in the morning (Eye opener)?
If no signs of alcohol abuse or dependence then patient can still have “at risk drinking”
Signs of alcohol abuse:
- risk of bodily harm
- relationship affect
- role interference (Work/family)
- run-ins with the law
Signs of alcohol dependence:
- craving alcohol
- loss of control (inability to cease drinking)
- withdrawal symptoms
- tolerance
Brief intervention
- state drinking is medically unsafe
- ask willingness to reduce alcohol intake
- negotiate goal (abstience is best)
- offer support
- screen often
Readiness to change: Pre-contemplation Contemplation Planning Action Maintaince
Support
- information
- addiction specialist (if dependance)
- support groups (AA)
- counselling
- medications (e.g. Disulfiram, Naltrexone)
Treat associated disorders (nicotine dependence, medical and psychiatric)
Medical manifestations of alcohol use:
- atrial fibrillation
- reflux
- macrocytosis
- peripheral neuropathies
- chronic pancreatitis
- chronic liver disease
- hypertension
- cardiomyopathy
- malignancy
- wernickes (ataxia, confusion, opthalmoplegia), Korsakoffs
