Long Cases Flashcards
Cystic Fibrosis
D - dx at what age, meconium,, recurrent sinus, ear of chest infection. If adult - heat exhaustion, steatorrhea, malabsoprtion, bowel obstruction, infertilit
R - Smoking/ Family history
P - Dyspnoea, Productive cough, hemptysis, Wheeze
I - CXR, CT, Bronch, Sweat Chloride, genetic testing
C - Cardiac (cor pulmonale), GI (cirrhosis) or T2DM
M - Regular physio, antibiotics, flutter device, mucolytics, bronchial aretry emoblisation
O- out
Bronchiectasis
D - recurrent chest infections, hemoptysis, weight loss, sinusitis, prepcipationg causes of exacerbations, infetriltiy
R -n/a
P n/a
I - Cl sweat test, Serum immunoglobulins, Bronchsopcy, CT, Eosinophilia, Sperm analsysis or nasal biopsy for ciliiary dysmotilty
C - hemoptysis, deteriorating lung function,
Tx - Pyshio, postrual drainage, mucolytics, antbiotics, IVIG, bronchial artery embolisation
Discuss - smoking cessation
Serum ig levels
prophylactic abs if more than 3 hosp admissions in a year - this has improved FEV 1
Lung transplant if FEV < 30%
COPD
Dx- age of diagnosis. sputum production, weight loss, dyspnoea, wheeze, weight loss, leg oedema
R - Smoking history, pollution, family history,
P - n/a
I - imaging, lung function tests, ABG, blood tests, ECG, alpha 1 antitrypsin,
C - pneumothorax, type 2 resp failure, cor pulmonale
M - smoking cessation, inhalers, home o2, pulmonary rehab, lung transplant
Issues: 1) smoking cessation 2) cachexia and malnutrution 3) lung transplant 4) impact on life and depression
Lung cancer
D - weight loss, hemoptysis, horners syndrome, pain, pleural effusion, night sweaths
R - smoking, asbestos, fhx, chronic scarring/fibrosis
P - loss of function
I - CT chest, bronch, PET scan, biopsy
C - pleural effusion, mets
M - chemo, radio, surgery, pall
O - Look for clubbing, pleural effusion, horners, lymph nodes,
Surgical consideration - stage 1 or 2 for NSCLC, or Limited small cell disease without mets or mediastinal disease
Inflammatory Bowel Disease
D - when was it diagnosed, bloody diarrhoea, mucous in stools, fever, bowel obstruction, pain,
R - smoking, family history
P - n/a
I - colonoscopy, endoscopy, stools
C - flares, number of colonoscopies, changes in medications, complications of surgery, bowel obstructions, infections, fistulas, extraintestinal manifestations
M -
IBD - extraintestinal manifestations
musculoskeletal: - migratory arhtirtis, ank spnd, sacroilitis Skin + rla - irits, episcelritis, anterior uveitis - apthous ulcers - pyoderma gangrenosum, erythema nodosum - clubbing Hepatobiliary - Gallstones - Malabsorption Renal stones Colorectal cnacer
Renal Transplant
Contraindications: Age >70
Malignancy, untreatable infection/ severe inflammation
Hx - how many, when, why
Graft characteristics - live/ cadaveric, related, HLA matched, CMV matched,
If recent operation - problems (infection, acute rejection, graft failure
Ix - Cr levels. drug levels, biopsies, HSV, BK status, quantiferon,
Tx - immunosuppresants
Complications - Chronic rejection, infections, SCC/ lymphoma, anemia, Met. bone disease, PVD/IHD
Immunosuppresion and its side effects
Pred - osteoporisis, deranged BSLs, HTN, prox. myopathy
Cycloscoprine - tremors, hirsuitism, chronic allograft neophroapthy, HTN, gout, hyper K, low mag,
Tacro - similiar to above, but more likely to neuro and nephrotoxcity
azathioprine - BM tox, hepatotoc
MMF - diarrhoea and cramping, hepatotox
Sirolimus - hyperlipidemia, Thrombocytopaniea
CCF
D - when, presentations to hospital, exercise tolerance on good days,
R - NSAID use, Family history, Valvular heart diseas,e Thyroid disease, HTN, Sleep apnoea
P - LVF symptoms - orthopnea, PND, dyspnoea on exertion. RHF symptoms, NYHA
I - TTE, TOE, Gated heart scan, angiography, RHF, Viral studies
Tx - Non pharmacological - fluid restriction, low sodium diet, cardiac rehab, pharmacologically with ACEi/ARB, aldactone, beta blockade,
Device theapy with CRT , ICD or PPM
Consider for transplant
Chronic Renal Failure
D - when. nocturia, loss of appetite, lethargy
R - Diabetes, HTN, UTIs/ past episodes of ARF, analgesia, PKD, disease (SLE/ Scleroderma/RA)
P - need for dialsysis, fistula creation,
I - renal tract u/s, doppler scan, serum cr, tests for proteinuria, renal biopsy, percentage of renal function
C - hyperkalemia, osteoporosis, hyperparathryroidism
M - fluid/salt/protein restriction, adherence and impact on life, anemia and EPO use, bone disase and calcium/vit d use, plans for dialsysi (Hd vs PD), plans for renal transplant
Social: pt preference, able to get to dialsysi centre, smoking and alcohol
O/E general volume status, lying and standing BP, skin (bruising, scratch marks, SCC), fistulas (new and old). Transplant scars, palpable kidneys
Signs of chronic steroid use
Parkinsons disease
D - when and how did symptoms start? Tremors, bradykinesia, rigidity, postural instability
R -
P - dementia, depression visual hallucinations, vertical gaze problem, dysarthria, postural dizziness, incontinence
psych hx - depression, hypersexuality, gambling, visual hallucinations
I - clinical
C - On/Off phenomenon, degree of involutary dyskinesia when drug is working,
- how quickly does one transition between the two
- frequency of falls
Complications of therapy - dystonias, dyskinesia
Long case - Falls and risk modifications
History of falls Imabalance/poor gait Visual impairment OA Postural Hypotension/Dizziness Meds Co morbidities
AIH
- PT for balnce assessment
- OT for home assesment re: rails in the shower, steps in the house, general tidiness, use of proper footwear
Social work - consider saftey at home, need for carers, personal alarm
Vasculitis
Dx - P/w Constitutional symptoms: fever, malaise, Fatigue, Arthralgia, Myalgia
or Stroke, seizures, Epsitaxis, Hemoptysis, MI, GI bleeds, Renal Impairment/Hematuria, Sensory problems/ skin (prurpura, raynauds)
Specific symptoms:
wegeners: nasal congestion, cough, hemoptysis, sob
GCA: Headaches, jaw claudication, Visual probs, CVA
PAN: constitutional symptoms, look for hx of hep b
Churg strauss: asthma, eczema, rhinitis, peripheral neuropathy,
MPA: Pulmonary renal disease
cryo: raymauds, arthritis, neuropathy, look for hx of hep inv: normochromic normocytic anemia, pANCA, cANCA, ESR, CRP, eosinophil levels, serum cryos, consider biopsy of site
Stroke
Dx: when, what affected ( weakness, numbness, vision, speech, coordination) time to hospital, thrombolysis
Ix: CT, MRI, TTE, TOE, Holter, Doppler U/s, ECG, Fasting BSLs/lipids, APL screen,
Mx: managed under stroke unit? antiplatelet, antihypertensives, statin, anticoag, CEA, CAS
Rehab:
Physical: Transfer, steps, toileting, showering, Dressing, Balance, Swallowing, APhasia, ASpiration risk, loss of hand function (ask re: handedness)
Cognitive: tasks (eg using microwave), depression and dementia
Discussion:
1) Potential for institutionalisian
2) Needs much greater support to function independetnaly in community
3) Metabolic risk factors and control
