Med 2017 2 Flashcards
63F - PCx: aching shoulders & hips for past month
not noticed any weakness but pain is affecting her activities
feels tired
appetite is good. weight is stable
PHx: hypercholesterolemia - 3 months ago, treated with Simvastatin
Assess and manage.
Diagnosis: Statin-induced myopathy (SIM)
DDx: fibromyalgia, myositis (dermatomyositis, polymyositis), and arthritis
History:
- Symptoms of statin-induced myopathy:
+ classic presentation: proximal symmetrical muscle weakness and/or soreness with functional deficits (e.g. unable to raise arms above head, unable to rise from a seated position, unable to climb stairs)
+ onset of symptoms relative to statin treatment: tends to be within weeks-months of initiation of statin
- Rule out rhabdomyolysis: muscle pain, nausea, vomiting, abdo pain, fever, tachycardia, dark urine, altered consciousness
- Risk factors for SIM:
+ liver or kidney failure
+ hypothyroidism
+ those take drugs that inhibit CYP450 3A4 system
Examination:
- Vitals
- U/A: rhabdo shows blood
- MSK exam: of affected joints et al
- Neuro exam: for power
Investigations: SIM is a clinical diagnosis, confirmed with patient improvement after cessation of statins
Additional tests may be helpful: - Lab: \+ serum CK \+ urinary myoglobin: check for myonecrosis and rhabdomyolysis \+ EUC: for AKI \+ vit D, TFTs: elevated TSH, low T3/T4.
- Imaging: X-ray of affected joints - screen for OA, RA
Management: mainly pharmacological
- Cease statins
- Consider switching to another type of statin (e.g. fluvastatin/pravastatin), or other classes of cholesterol-lowering drug (fibrates, bile acid binding resins)
- Treat vit D deficiency, hypothyroidism if present (as they worsen myopathy).
36F - PCx: almost daily headaches for past 3 months
otherwise asymptomatic
Assess and manage.
Diagnosis = Tension headache
a type of chronic headache
DDx:
- other headache syndromes: migraine, cluster headache
- space occupying lesion
- trauma
- infection: encephalitis (rare)
- rheumatological: giant cell arteritis
History:
- Symptoms:
+ pain history: SOCRATES et al e.g. age of onset, triggers (psychological stress, financial/relationship issues, etc.) - Rule out red flags:
+ space-occupying lesion: signs of increased ICP e.g.
- early morning headache
- a/w changes in posture/vomiting
- personality changes
- changes in cognition/consciousness
- seizures
+ stroke/CVA:
- neurological deficits
- severe headache
+ trauma: head injury
+ infection:
- meningism: neck stiffness, photophobia and headache
- altered consciousness
+ giant cell arteritis:
- visual disturbance
- jaw claudication
- Medications and allergies:
+ meds can cause headache as SE: CCB, nitrates, dipyridamole
+ headache as after acute withdrawal of a drug: alcohol (hangover headache), analgesics withdrawal (aka medication overuse, rebound headache)
+ COCP
Examination:
- Vitals
- Cranial nerve examination: look for CN palsies, raised ICP (via fundoscopy) -> mass, infection
- GCA: palpate temporal arteries, assess for jaw claudication
Investigations:
Chronic headache is a clinical diagnosis. Investigations are only performed if suspect a secondary cause.
If patient presents with classic symptoms of a type of chronic headache e.g. tension, migraine and their neuro exam is normal, may not need to do ix.
If suspect secondary cause, do MRI brain: look for stroke, vascular lesion, mass, infection.
Management: depends on the cause of headache
- Non-pharm: similar for all types of headache
+ Avoid headache triggers: stress, certain foods, poor sleep
+ Rest in a quiet, dark room
+ Avoid activities e.g. reading, watching TV - esp. for migraines
+ Encourage headache diaries: document episodes of headaches, associated symptoms, triggers
+ CBT: for coping skills, relaxation techniques
+ Modification of SNAP risk factors
+ Discourage over-reliance on caffeine - Pharm:
1) Migraine:
1st line = Paracetamol 1g PO 4hrly
OR Aspirin OR another NSAID
Add Metoclopramide 10-20mg PO (anti-emetic) if need be
2nd line = Triptans (agonist serotonin receptors) PO/nasal
3rd line = Dihydroergotamine SC/IM
used in refractory migraine
works similarly to triptans
2) Tension headache:
1st line = Paracetamol
if headache is chronic and unremitting, give preventer e.g. TCA amitriptyline 10mg PO.
3) Cluster headache:
Mainstay = preventive therapy
1st line = Oxygen + Prednisone PO + Verapamil (preventer) PO
60M - PCx: motor fluctuations of Parkinson’s disease (control of motor symptoms is not as good as it was)
BG: Parkinson’s disease for 6 years
on Levodopa/Benserazide for 4 years
Manage.
Diagnosis: motor fluctuations
‘wearing off’ phenomenon i.e. having an end-of-dose effect < 4hr following a dose of Levodopa
DDx: SEs of levodopa, poor compliance with therapy
History:
Symptoms:
- Recurrence of motor symptoms: resting tremor, bradykinesia, rigidity, postural instability, shuffling gait, stooped posture, dysarthria
- Non-motor symptoms:
+ Autonomic symptoms: orthostatic hypotension, bladder dysfunction, constipation, sexual dysfunction
+ Psychiatric disturbances: depression, anxiety, dementia and psychosis - Drug dosages: of Levodopa, and whether a second anti-Parkinsonian drug has been added?
+ characterise when motor symptoms occur?
+ ask about increasing predictability of these motor fluctuation episodes - Infective symptoms: untreated UTI can cause worsening of Parkinson’s symptoms
Examination:
- full Neuro exam: focus on motor disturbance e.g. gait
Investigations: not needed at this stage
Management:
Main aim of treating advancing PD is to treat the motor and non-motor symptoms of PD.
Motor symptoms:
- Non-pharm:
+ Avoid taking Levodopa with high-protein meals: because proteins compete with levodopa for amino acid transporters in the gut
+ Regular dosage times
+ Group support, exercise, good nutrition - Pharmacological:
+ If patient is taking low dose and not experiencing SEs (common SEs of levodopa are nausea, vomiting, postural hypotension, motor fluctuations and dyskinesias), increase the dose.
+ Shorten inter-dose intervals
+ Change to sustained-release preparations of Levodopa
+ Add a second drug: - Dopamine agonists: Apomorphine SC
- COMT inhibitors: Entacapone
- Surgical: high-frequency brain stimulation of internal portion of the globus pallidus.
Daughter of 79yo woman is concerned about mother who has pancreatic cancer, not expected to survive for more than few months
Daughter seeks advice about her mom, who lives alone, should be cared for?
Manage?
Diagnosis: Palliative care of a patient with pancreatic cancer
Main aim = make this woman’s life as comfortable as possible
Prioritise quality over all else
Coordinate a multi-disciplinary approach
History: - Re her pancreatic cancer: \+ when it was diagnosed? \+ treatments? \+ complications \+ disease trajectory
- Ask about advanced care directive/NFR (not for resuscitation).
- Ask about her family: how many members?
- Ask about patient’s biopsychosocial factors:
+ activities of daily living (ADLs)
+ capacity: does she have capacity to decide how she is to be cared for?
+ physical: pain and symptom control - SEs of opioids
- obstructive jaundice, gastric outlet obstruction
- immobility
+ emotional: depression, anxiety, unresolved issues in the family
+ spiritual: religious, non-religious - Multi-disciplinary team includes:
+ specialist palliative physician, nurses
+ general practitioner
+ other medical specialists: e.g. oncologist
+ allied health staff: pharmacist, occupational therapist, speech pathologist, dietician, social worker, grief and bereavement counsellor.
+ pastors - Discuss options if patient is unable to live alone any longer:
+ Hospice care: for patients not expected to live longer than 6 months
+ Aged care facility
All decisions must be made in consultation with patient and their family.
23F - PCx: recurrent UTIs
Assess and manage.
Recurrent UTIs i.e.
- at least 2 infections in 6 months
- at least 3 in 1 year
Assuming patient is stable and not have pyelonephritis (nausea, fever, flank pain, costovertebral angle tenderness and pyuria; would need IV fluids + abx). Proceed with history.
History:
- UTI symptoms: dysuria, burning, frequency, urgency, haematuria, lower abdo pain, fever
- Risk factors: \+ behavioural: sex, wrong wipe technique \+ pregnancy \+ immunosuppression: diabetes, CKD \+ stones \+ nosocomial (healthcare/hospital-related) factors e.g. instrumentation such as IDC (urinary catheter), ureteral stenting, etc. \+ anatomical abnormalities: PKD (polycystic kidney disease), VUR (vesico-ureteral reflux) \+ voiding dysfunction: MS, cystocele
Examination: - Vitals: make sure not in shock - Genitourinary exam: \+ signs of chronic renal impairment: oedema, uraemia, scratch marks, altered consciousness \+ pyelonephritis: flank pain \+ cystitis: lower abdo pain
Investigations:
- Bedside: U/A (elevated nitrites/leukocytes/blood/protein)
- Lab:
+ urine MCS
+ FBC: elevated WCC
+ EUC: elevated Cr and urea in CKD - Imaging:
+ Renal US: look for kidney stones, abscess
+ Cystoscopy: visualise the bladder, look for tumours/foreign bodies
+ Abdomen/pelvis CT scan: look for anatomical defects - fistulae
- VUR: with hydronephrosis
Management: depends on underlying cause of UTI
- Non-pharm:
+ correct wipe technique: front to back (prevent organisms from GIT to spread to urethra)
+ manage risk factors: treat diabetes, etc.
- Pharmacological: \+ Treat the initial infection: options are * Trimethoprim: 1st line (OD for 3 days) * Cephalexin * Amoxicillin + Clavulanic acid * Nitrofurantoin
Trimethoprim is 1st line because it’s OD and 50-60% of E. coli are resistant to penicillins.
82F - PCx: shortness of breath
found to have moderate-sized left pleural effusion
Assess and manage.
DDx of pleural effusion: - Transudative (i.e. little protein in the fluid): \+ Heart failure \+ Liver failure: hypoalbuminaemia \+ hepatic hydrothorax \+ Nephrotic syndrome \+ fluid overload
- Exudative (i.e. more protein):
+ Infections: TB
+ Malignancy: lung cancer, mesothelioma, lymphoma
+ Vascular: PE, pulmonary infarction
+ Auto-immune: lupus, rheumatoid pleurisy
Main aim: determine the cause of her pleural effusion and treat accordingly.
Resuscitation:
If she is in severe respiratory distress, would need resuscitation ABCDE.
- Breathing: assess RR, SpO2; give Oxygen
Once stable, proceed.
History:
- Symptoms: respiratory e.g. dyspnoea, wheeze, cough + sputum (infection), haemoptysis (malignancy)
+ do a systems review: screen for DDx
- Risk factors:
+ smoking
+ Transudative: cardiac history, liver failure, renal failure
+ Exudative: infective symptoms, features of malignancy (haemoptysis, unexplained weight loss, anorexia, history of PE/VTE, connective tissue disease - Meds: anti-coagulants -> chest drain would be contraindicated if patient on anti-coagulants
Examination: - Vitals - Full cardio-respiratory exam: \+ Pleural effusion signs: * asymmetric chest expansion * decreased air entry * decreased vocal resonance * stony dullness to percussion - Systems review: look for features of chronic liver disease and connective tissue disease.
Investigations:
- Bedside: SpO2
- Lab:
+ Bloods: FBC, EUC, LFTs (protein, albumin), LDH, CRP
+ Pleural fluid analysis: according to Light’s criteria, exudative or transudative. Exudative fluid would have:
- PF protein : serum protein > 0.5
- PF LDH : serum LDH > 0.6
- PF LDH > 2/3 of upper limit of lab normal serum LDH
+ Microbiology: 2x blood cultures, sputum MCS, pleural fluid MCS
- Imaging:
+ CXR: PA + lateral
+ CT chest - Management:
+ Most cases = Thoracocentesis for therapeutic and diagnostic reasons
+ Supportive = Oxygen, analgesia
+ If malignancy, MDT team with medical oncology, surgeons and allied health professionals.
+ Treat infection: give antibiotics, fluids. Drain the empyema.
+ Treat CCF: with LMNOP.
68F - PCx: abdominal distension
O/E: 10cm shifting dullness, no organomegaly
Assess.
DDx for ascites:
- Liver cirrhosis: 80%
- Malignancy: 10%
- Heart failure: 3%
- Nephrotic syndrome
- Tuberculosis: 2%
- Pancreatitis: 1%
Causes of cirrhosis:
- infection/hepatitis
- drug related: alcohol, methotrexate
- autoimmune
- hereditary: Wilson
- endocrine: NASH
1) Rule out life-threatening DDx that necessitate emergent management e.g. SBP, encephalopathy (due to liver failure). Hence proceed with history et al.
2) History:
- Symptoms:
+ Ascites: onset, duration
+ Cirrhosis symptoms: confusion, jaundice, easy bruising, leg swelling
- Risk factors:
+ Hep B/C infection: needle sharing, tattoos, multiple sexual partners
+ Drugs: comprehensive alcohol and med history
+ Auto-immune hepatitis
+ Hereditary: Wilson’s
3) Examination:
full gastro
4) Investigations:
- Lab:
+ Bloods: FBC, platelets, EUC, LFTs, alpha fetaprotein (AFP) for HCC
+ Serology
+ Ascitic fluid test
- Imaging:
+ Fibroscan
+ Liver biopsy
+ CT abdomen/pelvis
+ whole body PET-CT scan
