Management Flashcards
SNAP Protocol
Smoking
Refer to Quitline
Few options – NRT, Varenicline
Nutrition
Overall – Mediterranean Diet
Inc intake of vegetables, Fruits and wholegrain
Low in salt
Dec. Red meat – Inc Fish
Dec Saturated fat like butter
Inc. Unsaturated fat like olive oil
Alcohol
Cut down alcohol intake
No safe level of drinking
Keep Alc <10 SD/wks, <4SD on one sitting.
2 Alcohol free days
Physical Activity and Weight
At least 150 mins, mod-high intensity exercise per week
Weight Management
BMI <25
WC <94 in Men, <80 in Female
Hyperlipidemia Mx
- r/o Sec Cause - DM, TFT, KFT
- Pharmacologic Management - Aus Risk Calculator
- If High we start Statins - Atorvastatin
- Aim at TC <4, LDL & TG <2, HDL >1 - Non-pharma - SNAP Protocol
How to Use Automated BP Device
- Calibrated BP Device
- Cuff should be 80% Length and 40% Width of the Arm Circumference
- Put Cuff in Bare Arm w/out thick Clothing
- Place Cuff above the elbow, Midpoint of the cuff should be at the midpoint of the arm.
- Tighten the Cuff in a way that you can slip 1-2 finger in between.
- Make sure the tubes fall in front of elbow - Sensor
- Place your arm on the desk and Relax
- Press the start button
- Record and Write down both Numbers
Secondary Hypertension Inv.
TFT
Abdominal Ultrasound/ Doppler
2D Echo
Saliva
Urine ACR/ eGFR
Urine Metaneprine
Aldosterone/Renin Ratio
XX
Sleep Studies
Aortic Abdominal Aneurysm Mx
Non-Pharma - SNAP
Meds - Statins, Anti-HTN (ACEi), Aspirin
Surgery if - >5.5cm(M), >1cm/yr, w/Sx
F/U - Depends on Size, USD at least 2yr
Family f/u - ~65 y/o USD for Screening
Notify Driving Authorities
- Untreated AAA - Conditional License
- >5cm No driving
Assess other blood tubes in the body
Do Investigations
Hypertensive Urgency Criteria & Mx
Criteria - >~180/110 + Symptoms
Refer to ED
Inv. r/o Endorgan Damage
Meds - Captopril 12.5 SD
Treat HTN - Initiate Meds
SNAP
HTN Emergency Criteria & Mx
Criteria - >~220/140
Refer to ED
Inv. r/o Endorgan Damage
Meds - Captopril 12.5 SD
Treat HTN - Initiate Meds
SNAP
OCP Induced HTN Mx
Stop OCPs, Use other Methods
Monitor BP
Investigations - TRACKPADS
SNAP
Diabetes Mx
Investigation (End-Organ Damage)
- Eyes, Legs, Heart, Kidney
Pharma - Metformin
Non-Pharma
- SNAP Protocol
- Activity - >5mmol BSL before exercise, Carry Jelly Bean Always
- Hypoglycemia - Rule of 15s
- Weight Loss - ~7%
BSL Monitoring
Referrals - Podiatrist, Diabetic Educator, Ophtha, Nephro
Inform DLA (if w/ Meds)
Sick Day Management
Glucometer Procedure
Wash hands and Prepare Equip (4)
Check Strip Due Date and Put in Glucometer. Turn On
Lancet to the Lancing Pen. Prime
Prick the Side of Finger. Wait for Results
Band Aid and Clean Area
Record Findings. Done before BF and 2 hours after meals
Gonorrhea Mx
Ceftriaxone + Azithromycin
Contact Tracing and Notify DOH from last 2 months
No sex for 7 days
No sex with partners from last 2 months
Test of Cure at 2 weeks
Re-Test at 3 months
Safe Sex - Condom, Partner, Avoid High Risk
Reading Material - Drama in Down Under
Chlamydia Mx
Doxycycline
Contact Tracing and Notify DOH last 6 months
Notification of the Lab
No sex with partners from last 6 months
No sex for 7 days
No Test of Cure
Re-Test at 3 months
Safe Sex - Condom, Partner, Avoid High Risk
Reading Material - Drama in Down Under
Gonorrhea + Chlamydia Mx
Ceftriaxone + Doxycycline
Contact Tracing and Notify DOH
No sex for 7 days
No sex with partners from last 6 months
Test of Cure at 2 weeks (Gono)
Re-Test at 3 months
Safe Sex - Condom, Partner, Avoid High Risk
Reading Material - Drama in Down Under
MSM Advice Mx
Explain STI’s
Safe Sex Advice
STI Test - Every 3 Months
HIV PrEP
- Step 1 - Checking if eligible
- Step 2 – Confirm HIV Status and KFT
- Step 3 – STI Screening
- Step 4 – Prescribing PrEP
- Step 5 – Ongoing Monitoring
STI Tests
Gonorrhea and Chlamydia - Swab and First Pass Urine
Syphilis - VDRL
Hepatitis B - Hepatitis Titer
HIV - Serology
Warfarin Counselling
Warfarin Desc, INR
Result Interpret – 2-3,
Schedule – How to take it, INR Test – Everyday once ok, Every month
Complications - if <2 - Clot, if >3 – Bleed
Interactions
– Other Meds, OTC, Herbal,
– Diet, Leafy (Dec), Grapefruit (Inc),
– Alcohol, Sickness
Missed Dose - <4h Take, >4h Skip, Never Double
4R’s
NOAC Counselling
Condition - Anti-Coagulant, CHADSVasc, Thombosis
M - NOAC
A - No Regular Testing, No Bridging, Fast Effect, Less Interaction
D - Does not have antidote, CI in CKD, Mech Valve, Mitral Stenosis, SE Bleeding
D - Taken Everyday at the same time frame, Never Double Dose
Steps in changing from Warfarin to NOACs
Stop Warfarin
INR everyday
Start if INR <2.5
Pre-Op Management
Before
Bleeding Risk - Procedure and HASBLED
- Low - Cont Warfarin
- High - Stop Warfarin 5 days before
Clotting Risk - Conditions and CHADVasc
- Low - No Bridging
- High - Bridging Therapy, Enoxaparin start if INR <2 (Stop 6 hrs before)
Antibiotics if (+) Mechanical Heart Valve
After Surgery
Enoxaparin - Start 6 hours
Warfarin - After 24 hours
Stop Enox once everything is under control
Time need to stop Meds before Surgery?
Warfarin, NOACs, Metformin, SGLT (Flozin)
Warfarin - 5 days
NOAC’s - Depends on KFT 1-3 days
Metformin - On the Day
SGLT- 3 days Prior
DVT Mx Counselling
Condition, Clinic Presnt, Complication – DVT, COSTVMPF, PE & Post Thrombotic Synd
Management – NOACs, Warfarin
Advantage & Indications
– NOACs – No monitoring, Fast Effect No Bridging Req, Less interaction,
– Warfarin – Regular Monitoring, Slow need Warfarin, More interaction
Disadvantage – Risk, S/E, & CI
– NOACs – Cannot be used in CKD, Mechanical Valves
– Warfarin – Regular Monitoring, Slow need Warfarin, More interaction, CI in Pregnant
– SE of Anticoags – Bleeding, Pain,
Dose and Duration – Taken Everyday at the same timeframe, Never Double Dose
COPD Mx
C – Confirm diagnosis – X-ray, Spirometry, ABG r/o CVD
O – Optimize Lung Function
- Steps in Meds, Nutrition and Diet
- Chest Physiotherapy
P – Prevent deterioration (Worsening)
- Stop Smoking
- Vaccines
D – Develop Support and Plan
- Pulmonary Rehab
X - eXacerbation
- Steroids - Flare Ups
- Antibiotics - If w/change in CCVO of Sputum
COPD Medications, Step Ladder
Step 1 - SABA
Step 2 – Add LABA
Step 3 – LABA + LAMA
Step 4 – LABA + LAMA + ICS (Depends)
Osteopenia Mx
Garvan Calculator
High Risk - Meds
- Alendronate - Oral Meds, Daily 5 years Max, SE - Nausea, Vomiting
- Denosumab - Injections, Every 6 Months, Can get Worse if Lost to ff up
Ca Supplements - Diet if not able, Meds
Vit D Supplements
Non pharma - Exercise and Diet, Sun Exposure, Alcohol and Smoking
Asthma Treatment
Step 1 - SABA
Step 2 - SABA + LD ICS
Step 3 - SABA + LD ICS (+ LABA or Montelukast (Pedia))
Step 4 - SABA + MD ICS + LABA
3 Months of Control Before Stepping Down
Fall Reduction Strategies
Refer to Fall Clinic
Physiotherapist - Balance and Exercise
Occupation Therapist - Home Review
Podiatrist
Vision and Hearing Assessment
Medication Review
General Fracture Care
Pain Relievers
Elevate, Ice - Reduce Swelling
Avoid Getting the Cast Wet
Maintain the Cast Clean
If Itchy Avoid putting things in the Cast
Use Hair blower in Cool Mode
Still Move your Fingers
Fracture Mx in Elderly
General Fracture Care
Redflags (Compartment Sx)
Physiotherapist
Osteoporosis Mx
Fall Reduction Strategies
Prostate CA Mx
Surgery - Keyhole Surgery
- After Tx - Need to monitor PSA
- SE - Erectile Dysfunction, Retrograde Ejaculation
Radiotherapy or Brachytherapy
Hormonal Tx - Meds or Testicular Surgery
Wait & Watch - Gleason =< 6, >70 y/o
IBD Mx
Inflammatory Bowel Disease
Meds
- Steroids
- Sulfasalazine,
- Methotrexate
- Surgery if no Response
Non-pharma
- Investigations - TB, Hepatitis
- Vaccinations - Influenza and Pneumoccocal
- More Regular Monitoring (Colonoscopy) - UC
Hemochromatosis Mx
Test Primary Family Member - if (+)
- Iron Studies - Ferritin, Transferrin Saturation = High
- Genetic Studies - C282Y, H63D
– 2 C282Y - Test wife
– 1 C282Y or 2 H63D - No need follow up
– 1C282Y AND 1 H63D - Iron Lvl every 2-3 yrs
Management
- Life long blood donation - Every week until normal then every 2-3 months
- Deferroxamine Tablets
- If Iron Storage is lowered before organ damage = Normal Life-expectancy
Avoid
- Alcohol, Vit. C
Alcoholic SN Mx
Immediate
- Refer to Neuro - Nerve Conduction Studies
- Gabapentin - If Problematic
- Thiamine
Long-Term
- Cessation of Alcohol
- Podiatrist
- Fall Prevention Mx
Alzheimer’s Disease Mx
Referral - Aged Care Assessment - Asses what level of support he needs
- Social Worker Visit few times a day or
- Nursing Home
Investigation - TFT, BSL, B12, LFT, KUB
Meds - Donepizil
Reduce Risk - Mood (SSRI), Med Review, Vision and Hearing Check
Advance Care Planning
Healthy Lifestyle
Driving Notification
Support Group - Dementia Australia
Private Driver License Mx (1st Episode)
Seizure Free for 6 months
Started Treatment for 6 months
Address RF - Alcohol, Sleep, Drugs, Medications
Inform Driving Authority (If 1st time)
Follow Up
Methotrexate Preparation
Vaccination
Folic Acid Supplement
FBE, LFT
Palliative Care
PEPSI COLA
P - Physical Symptoms - Pain Meds, Stop Non-Essential
E - Emotion - Provide Support and Expectations of the Difficult situation
P - Personal - Religious Need
S - Social Support - Center Link & Social Worker
I - Information and Communication - Schedule a consult with Consultant
C - Control - Respect Advance Directive
O - Out of hours
L - Late
A - Afterwards
Epistaxis Management - Step Wise
Squeeze Nose 10-15 mins, Leaning forward, Head Slightly Tilted Forward
If stops - Check Vessel - Anestetic Spray then Apply Silver Nitrate
If stops - Vessel Not visualized - Use Merocel + Oral Ab
If it dosen’t help - Refer to ENT and insert Foley Catheter then Inflate
Stop Nasal Steroid Change to Anti-Histamine
Rheumatiod Arthritis Mx
MTX or DMARDS
Steroid Short Course
NSAIDS for Pain
Prior to Start - Vaccinations, Folic Acid Supplement, FBE & LFT
Non-Pharma - Physiotherapist, OT, Excercise Physiologist, Psychologist
Lifestyle Change
Goal of treatment - Symptom Free, Control Symptoms, AOD
Delirium Mx
Usually Multi Factorial
Treat Underlying Cause (ex.)
- Hyponatremia - Restrict Fluids, PNSS if Severe
- Hypoxia - Give oxygen
Do Further Investigations
Supportive Treatment
- Familiar Environment - Family Members, One Nurse,
- Room Quiet Well lit, Normal Temperature
- Calendar and Clock
- Regular Communication
- Safe Environment
Haloperidol or Olanzapine - If High Risk of Harm
Diltiazem, Statin, Interaction Mx
Diltiazem
- If for HTN - Change to another class
- If for CHF - Liase with Cardio
Temazepam Dependence Mx
Taper Dose
Change to Long acting
Taper 10-25% dose every 1-2 weeks
Arrange daily pick up
HTN Mx (Medication)
First Line Medications
ACEi/ARB (Perindopril)
- Ad: Protects the Kidneys
- SE: Dry Cough, Inc. K, Drop in Kidney Func.
- Dis: Need to check KFT after 2 weeks
– Cont. if eGFR change is <25%
- CI - Pregnancy, Angioedema, Hyperkalemia, Bilateral RAS
CCB (Amlodipine)
- SE: Swelling of the leg
Thiazides
- SE: Postural Hypotension, Frequency of Urination, Drops K
- Dis: Interacts with other Medication
- CI - Gout
Peripheral Arterial Disease
Inv - USD Doppler, CT Angiogram, Metabolic Panel
Manage Risk Factors
Pharma - ACEi, Cholesterol, Aspirin
(If has B-Block - Change)
Non-Pharma
- SNAP
- Exercise Physiotherapist
- Podiatrist
- Monitor Ulcers
Surgery - ABI <0.3-0.4 - Vascular Surgeon
HTN Mx (Steps)
Step 1 - First line Drug + Lifestlye
Step 2 - Add 2nd Drug
Step 3 - Increase dose of 1 drug before inc the 2nd drug
Step 4 - Max 1st and 2nd Drug + 3rd Drug
Step 5 - Refer to Specialist
Give 3 months before stepping up
HTN Investigations
Check 2ndary HTN - TRACKPADS
Check Complications
- Kidneys - eGFR, Urine ACR
- Heart - 12L ECG, 2D Echo
- PAD - Ankle Brachial Index
Check Metabolic Panel
- FBS
- Lipid Profile
- BUA
