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Phase 3 Exams > Med 2017 Release > Flashcards

Med 2017 Release Flashcards

1
Q

A 67 year old man has been experiencing chest pain on exertion for several weeks and is to have a coronary angiogram. How would you explain the risks and benefits of the procedure and how it will be performed?

A
  • Done to determine extent of coronary artery disease and maybe fix it (with PCI)
  • Only done if about to PCI OR (in this case) mod-high risk of another event or max medical therapy not working
  • Day procedure - preop bloods, catheter in +/- PCI, postop 6 hr recovery
  • Risks of sticking a catheter through - artery dissection, arrhythmia, thrombus/embolism
  • Can try CTCA instead, but not the best at characterising disease
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2
Q

A 54 year old man complains of intermittent palpitations. He has no history of cardiac disease or hypertension. The ECG shows atrial fibrillation. How would you manage him?

A
  • Can be caused by thyroid, infections
  • Resus if necessary and cardioversion
  • Rate control, rhythm control, ?stroke prophylaxis
  • Dig is firstline if they have heart failure
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3
Q

A 26 year old female presents with tiredness, palpitations and heat intolerance. She has a diffusely enlarged thyroid. How would you assess her?

A
  • thyroid storm - treat with fluids, antithyroid drugs, iodine
  • eye signs: exophthalmos + consequences (GRAVES), thyroid stare, lid lag, lid retraction
  • mx: definitive AND symptomatic
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4
Q

A 68 year old woman presents complaining of abdominal distension. On examination she has 10cm of shifting dullness but no organomegaly. How would you assess her?

A
  • DDx is cirrhosis causes, malignancy, heart failure, nephrotic syndrome (and exudative causes: malignancy, TB, pancreatitis)
  • Ix with LFTs, coags, abdo U/S
  • Management - mild = Na restriction and if symptomatic, spironolactone; mod to severe = higher dose +/- frusemide, paracentesis
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5
Q

A 60 year old man develops a DVT in his right leg two months after stopping warfarin for a similar episode on the left. How would you manage him?

A
  • Is it provoked or unprovoked?
  • Is the provoking factor something you can treat?
  • Unprovoked is lifelong warfarin
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6
Q

A 36 year old woman has been experiencing almost daily headaches for the past three months. She is otherwise asymptomatic. How would you assess and manage her?

A

Kinds of headache: migraine, tension, cluster

MANAGEMENT
- headache diary
- non-pharm: physical therapy, psych (incl CBT)
- pharm:
SYMP: paracetamol +/- ibuprofen
DEF: (tension) amitriptylline, (migraine) triptans, (cluster) verapamil to prevent, O2 acutely

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7
Q

A 67 year old man with cardiac failure presents with increasing dyspnoea and ankle oedema. His current treatment includes frusemide and enalapril. How would you manage him?

A
  • If acute, LMNOP (POND)
  • If chronic, adjust CCF meds (captopril, carvedilol, frusemide) and consider adding aldosterone
  • Look for underlying cause and treat - patient factors (poor compliance, lots of Na and H2O), intrinsic cardiomyopath (MI, arrhythmia), extrinsic extra load on the heart (valvular dysfunction, meds that fluid retent, infections, anaemia, PE, thyroid, renal failure)
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8
Q

A 57 year old woman is diagnosed with intermittent atrial fibrillation on Holter monitoring after she presented complaining of palpitations. How would you assess and manage her risk of stroke complicating AF?

A

priorities:
1. stroke: do they need anticoag, are they safe on it
2. other AF compl: will they get CCF

  • CHA2DS2VASc: 2 start; 0 don’t
  • HASBLED: 3 pls avoid
  • general CVD/stroke risk for your own info

A=abnormal renal and liver function; BLED = bleeding event, labile INR, elderly, drugs+/- alcohol

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9
Q

A 60 year old woman has been found to have a fasting BSL of 14.7mmol/L. She attends the Diabetes Clinic for the first time. How would you assess and manage her?

A
  • assess to confirm diabetes, check for complications and assess CVD risk/metabolic syndrome
  • management is non-pharm, pharm, multidisciplinary and follow up
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10
Q

A 35 year old man with chronic hepatitis C is to have a liver biopsy. How would you assess the risks and how would you assess him following the procedure?

A
  • benefit: assess severity of hep C -> prognosis, urgency of treatment, enable transplant
  • risks: RUQ/shoulder pain, n+v, muscle aches, bleeding (-> shock), bile peritonitis, perforation/damage to surrounding structures (lung, gallbladder, bowel), DVT/PE, infection (rare)

assessment

  • past history
  • comorbidities
  • clotting disease hx
  • bleeding: bleeding diathesis, anti-thrombosis, coags and FBC, UEC (uraemia affects platelets)

procedure

  • percutaneous vs transjugular
  • close monitoring after procedure
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11
Q

A 58 year old man presents with a two month history of right upper quadrant discomfort and weight loss. His liver function tests are normal but a CT scan of his abdomen shows a solitary mass in the liver. How would you assess him?

A

DDx:

  • benign solid (hepatic haemangioma, focal nodular hyperplasia)
  • malignant solid (liver, gallbladder, mets)
  • cystic (simple, cystadenoma, cystadenocarcinoma, hydatid)

Ix: US, MRI if solid
Look for HCC causes

  • follow up benign lesions
  • if malignant lesions are too big, need to transplant or palliate (ablate, chemo, TACE)
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12
Q

A 35 year old previously well woman asks you for a drug to help her lose weight. She has a body mass index of 32 and is clinically well. She has a family history of type 2 diabetes. What would you advise her?

A
  • confirm obesity (exam - waist circumference and waist-to-height best)
  • find out why she’s overweight
  • CVD risk assessment
  • lifestyle changes
  • refer to bariatric unit if BMI > 40 or > 35 with comorbidity
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13
Q

A 76 year old woman, who is in a nursing home, has fallen over on two occasions in the past 3 days. How you would assess her?

A
  • likely age-related: assess cerebellum, eyes, ears, legs+gait
  • then others: D (?BP), M (?arrhythmia), E
  • unlikely to be delirium because should be confused etc
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14
Q

A 30 year old man is recently diagnosed with HIV following a routine test as part of a sexual health assessment. He is asymptomatic. How would you assess and manage him?

A

priorities

  • where is their HIV at
  • what complications do they have
  • do they have any other related health issues: STI, hep, AIDS infections
  • **AIDS: mouth (candida), lung (TB, PCP), skin (KS), lymph nodes (NHL)
  • ** start HAART if AIDS, CD4 l< 500, HCV coinfection, pregnancy
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15
Q

A 63 year old woman complains of aching shoulders and hips for the past month. She has not noticed any weakness but the pain is affecting her activities. Apart from the pain she feels tired but her appetite is good and her weight is stable. Her past health is unremarkable expect for hypercholesterolemia which was diagnosed three months ago and is being treated with simvastatin. How would you assess and manage her?

A
  • PDx: PMR but statin-related myopathy a DDx
    WORRIES: GCA, rhabdo

Assessment

  • History:
  • —HoPC: myalgia vs myopathy, morning stiffness ‘inability to turn over in bed’, no other joints involved, no systemic symptoms (apart from malaise - suspect GCA), assoc sx of temporal arteritis/rhabdo (myalgia, n+v, abdo pain, fever, dark urine, altered consciousness)
  • —PMHx (incl CVD risk), FHx, meds and allergies, SHx
  • Exam: MSK of shoulders, spine, hips and any other joints; check power too
  • Investigations: ESR, FBC, CK, EUC, urinalysis, vit D/LFTs/TFTs (may exacerbate), HC

Management

    • If GCA suspected, REFER URGENTLY: higher pred dose (40-60mg) and concurrent aspirin
  • Cease statin if CK elevated and see if symptoms resolve. Consider alternative treatment of HC.
  • Trial of steroids if no contraindication - expect response by 48 hours
  • Long term steroids (12 months): start with 15mg pred and taper
  • If ESR not elevated, consider differentials: PD, fibromyalgia, infection, malignancy
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16
Q

A 60 year old man has had Parkinson’s disease for six years and has been taking levodopa/benserazide for the last four years. He complains that the control of his symptoms is not as good as it was. How would you manage him?

A
  • work out what he means - motor vs non-motor symptoms
  • work out why - patient factors vs treatment factors (do symptoms get worse when drug wears off)
  • if motor: add the other drug (consider entacapone, selegiline); if non-motor: treat that
  • non-pharm includes: deep brain stimulation

**PD exam: mask-like facies, flexed posture, few spontaneous movements, shuffling gait, festination, bradykinesia, pill-rolling resting tremor, cogwheel rigidity, glabellar reflex, palilalia, weakness of upward gaze, seborrhoea, micrographia
**
postural hypotension: water, Na, fludricortisone
constipation: diet +/- laxatives
bladder: bladder drill, oxybutyrinin
sexual: counsel, drugs

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17
Q

A 65 year man with a long history of smoking presents with cough and weight loss and a mass is seen on his CXR. How would you assess him?

A

THIS IS A CANCER STATION. DO LUNG CA AS PDx and mention abscess, pneumonia as DDx.

Diagnose with bronchoscopy and transbronchial needle aspiration. Stage with whole body PET-CT because lung cancer goes errywhere.

Treat cancer (surgery +/- chemoradiation) and complications

***Paraneoplastic: PTHrP, Lambert-Eaton syndrome

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18
Q

The daughter of a 79 year old woman is concerned about her mother who has pancreatic cancer and isn’t expected to survive for more than a few months. The daughter seeks advice about how her mother, who lives alone, should be cared for. How would you manage this situation?

A

Palcare issues

  • ADLs
  • capacity +/- SDM, ACD
  • physical sx
  • emotional sx
  • spiritual issues

Multidisciplinary approach
- etc + counsellors, pastoral care

Living options

  • home
  • hospice care
  • aged care facility
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19
Q

A 23 year old woman presents with a history of recurrent UTIs. How would you assess and manage her?

A

Vast majority normal, but things like proteus spp, relapsing infection or delayed response might make you suspicious about stones (proteus) or anatomical abnormalities.

Priorities:

  • Confirm and treat UTI/pyelo
  • Corfirm ‘recurrent’
  • Look for behavioural reasons and counsel
  • Consider prophylaxis (trim/keflex): intermittent self-treatment, intermittent prophylaxis after sex, continuous prophylaxis for six months
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20
Q

An 82 year old woman presents with shortness of breath and is found to have a moderate sized left pleural effusion. How would you assess and manage her?

A

Worried about exudative (cancer, infection, inflammation, PE) or transudative (it’s oedema).

Look for the causes, starting with general things and pleural fluid analysis:
- biochem: does it have more protein and LDH than serum? (exudate) Also glucose, cholesterol, pH
- cell counts
Then look further depending on what you find.

Treat effusion: thoracocentesis.
Treat underlying cause.

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21
Q

60 year old woman with type 2 diabetes mellitus and obesity presents with an ulcer on the sole of her left foot. She reports this has been gradually increasing in size and has been weeping recently. How would you assess her?

A

Priorities

  • ?life threatening sepsis
  • investigate the things stopping it from healing: infection (incl osteomyelitis) and vascular supply
  • treat those (tazocin +/- vasc surg) and then wound care
  • treat DM and CVD risk
22
Q

An 87 year old man is fatigued and pale. His FBC shows Hb 78 g/L (>130), MCV 108 (80-100), platelets 168 (>140). How would you assess and manage him?

A

DDx: haemolysis, B12, folate, alcohol/liver/thyroid

Assessment

  • History: severity of anaemia (incl chest pain), symptoms of potential causes (neuro sx, haemolysis sx, cirrhosis sx) causes (diet, malabsorption, alcohol, hep etc); PMHx, MEDS (chemo, ART), rest of hx
  • Exam: jaundice, pallor, angular stomatitis/atrophic glossitis
  • Investigations: FBC and smear, haemolysis screen, B12 and folate, LFTs (incl unconjugated and conjugate bilirubin), UECs, TFTs if symptomatic

Management

  • Transfusion if IHD symptoms
  • B12, folate deficiency: supplementation and dietary change
  • Haemolysis: referral and management
  • Treat any other underlying conditions
23
Q

A 33 year old woman presents with a three month history of pain in her hands, wrists and feet. The pain is worse in the morning and associated with stiffness in the joints
lasting for about an hour. On examination there is swelling of the wrist and MCP joints with limited movement in the joints. How would you assess and manage her?

A

PDx: RA
DDx: SLE, scleroderma, psoriatic, IBD, gout, pseudogout

Priorities

  • Confirm diagnosis: inflammatory vs mechanical arthritis, distribution of joints, assoc sx (eg SLE, scleroderma, IBD, psoriatic); look for characteristic deformities + rheumatoid nodules on exam, psoriasis, sclerodactyly/raynaud’s, IBD eye signs
  • Investigations
  • –joint: xrays => (LESS) loss of joint space, erosions, subchondral osteopaenia, soft tissue swelling
  • –inflammation: ESR, CRP, FBC
  • –causes: RF, anti-CCF, ANAs, anti-dsDNA, ENAs (incl anti-Sm), C3, C4, serum urate; endoscopy/colonoscopy/stool calprotectin
  • –investigate any other potential complications eg pericarditis/pleuritis
  • Management (referral)
  • –DMARDs asap: methotrexate and folic acid (other options: leflunomide, sulfasalazine, etanercept, infilixmab)
  • –manage other effects: pain, psych, CVD risk, PUD, immunocompromise, fertility concerns
  • education
  • F/U
24
Q

A 52 year old woman is being treated by peritoneal dialysis for end-stage renal failure due to chronic glomerulonephritis. She presents with an acute abdomen. How would you assess and manage her?

A

PD-related is the most common cause. It usually presents less seriously than secondary causes.

Ix the peritoneal fluid:

  • MCS: get the bug, get the high WCC and neutrophilia
  • amylase and lipase: rule out secondary causes

ALSO inflammation bloods

Mx: empirical therapy is gent and ceph; if systemic sx/no response by D3, go looking for secondary causes

25
Q

A 66 year old man is in hospital being investigated for anaemia. He has a past history of stable angina and experiences an episode of angina only partly relieved by glyceryl trinitrate. How would you assess and manage him?

A

FIRST: ACS pathway
THEN: long term work up
- anaemia: look for sx and causes then give iron, treat underlying cause
- angina: assess sx and CVD risk, can try bblockers, Ca channel blockers; coronary angiogram if medical tx maxxed out

**
you can’t give bblockers and heart Ca blockers together, but you can add nonheart Ca channel blockers to bblocker

26
Q

A 68 year old man with known lung cancer is admitted for staging investigations. How would you assess and manage his risk of venous-thromboembolism during the admission?

A
  • rule out current DVT
  • assess DVT risk: if otherwise well and short stay with minor procedures, no prophylaxis; if any risk, clexane, if high risk - liaise
  • assess bleeding risk

***for everyone: early mobilisation, avoid dehydration

27
Q

A 72 year old man presents with recent onset of shortness of breath, dry cough and ankle swelling. He has a history of hypertension and takes indapamide. His BP is 130/95 and there are signs of congestive cardiac failure. How would you manage him?

A
  • LMNOP (POND)
  • look for and treat underlying cause (intrinsic, extrinsic, patient)
  • adjust CCF meds (CCF plus aldosterone)
28
Q

A 55 year old woman has been in hospital for two days with acute gastroenteritis. She has a history of polymyalgia rheumatica which has been treated with oral prednisone 10mg daily for several years. Her BP has fallen to 90/70 mmHg. How would you manage her?

A 
- ddx: c diff
Resus
- fluids, electrolytes
- bloods incl cortisol and ACTH
- steroids (dex if adrenal insufficiency unknown - 4mg every 12 hours)
Treat cause, 3 for 3 steroids rule

confirm with short synacthen when stable

**addisonian crisis: shock, abdo pain, n+v, anorexia, fatigue, confusion; hypoNa, hyperK, hyperCa

29
Q

A 72 year old woman with longstanding postural hypotension secondary to autonomic failure presents after a fall at home. Her right hip is painful along with her left ribs. How would you assess and manage her?

A
  • trauma assessment + fracture management
  • look for autonomic failure cause and treat (DM, PD)
  • treat postural htn: non-pharm (education, behaviour, water, Na), pharm (fludrocortisone)
  • look for other modifiable falls risk factors
30
Q

A 66 year old man has been hospitalised for treatment of acute prostatitis with ceftriaxone. His initial symptoms have resolved and his treatment is changed to oral ciprofloxacin. The next day he develops cramping abdominal pain, diarrhoea and fever. How would you assess and manage him?

A

this man has a c diff!

  • worried about toxic megacolon etc
  • GI surg, gastric acid suppression, enteral feeding are risk factors
  • o/e: DRE for blood; peritonitis = ?perforation
  • dx with stool PCR for toxin A and B
  • give met (PO/NG/IV)/vanc (PO!); cease antibiotic!, supportive care if necessary
31
Q

A 38 year old woman presents with a two day history of profuse bloody diarrhoea with fever. She was diagnosed as having ulcerative colitis 10 years ago and has been treated with salazopyrine and corticosteroids. She has not had any symptoms for the past three years and ceased all treatment six months ago. How would you assess and manage her?

A
  • if acute severe UC (Truelove and Witts criteria) fluids and IV steroids
  • restart therapy + consider maintenance therapy
  • escalate to immunomodulators or infliximab if failed trial
  • avoid meds that can precipitate toxic megacolon (hypokalemia, antimotility agents, opiates, anticholinergics, antidepressants, barium enema, and colonoscopy)
  • **truelove and witts:
  • no of bowel movements
  • blood in stool
  • pyrexia
  • anaemia
  • tachy
  • ESR
32
Q

A 36 year old man is admitted following a haemetemesis. His condition is stable and he is awaiting endoscopy. However he has a further bleed and his BP falls to 80/65 mmHg. How would you manage him?

A

RESUS

  • consider blood if Hb < 7 (?MTP), reverse coagulopathy
  • quick history for ?cause

supportive care: PPI, octreotide
contact surg for endoscopy

33
Q

An 86 year old woman admitted with pneumonia becomes confused. Her serum sodium is 119 mmol/L (135-145). How would you assess and manage her?

A

PDx: delirium 2o to hypoNa and pneumonia
- investigate other causes of HypoNa (hypervol, hypovol, euvol)
- fluid assessment
- fluid restrict if not hypovolaemic
3% saline if severe - but need to avoid cerebral oedema

34
Q

A 55 year old man is receiving a blood transfusion and develops rigors and vomiting. How would you manage him?

A
  • consider haemolysis, TRALI, sepsis + nonworrying differential (FNHR)
  • stop transfusion and contact blood service

RESUS, incl

  • ECG, resus bloods
  • haemolysis screen + ABO, blood culture, CXR

Mx

  • TRALI: resp and haemodynaemic support
  • AHTR: hydrate + diurese lots
  • platelets/FFP/cryo if DIC

***AHTR: hypotension, jaundice, hburia, hbaemia, oozing from IV sites, chest/back/flank pain

35
Q

A 67 year old man is admitted following a stroke. By the 5th day his neurological status is improving but he develops a fever. How would you assess and manage him?

A

Although it’s probs pneumonia, don’t forget noninfectious fever: VTE, drug fever

Septic workup.
Supportive care.
Abx - aspiration pneumonia is same as typical CAP if mild or moderate, cef and met if severe

Later - speech path review

36
Q

A 24 year old woman is admitted to hospital with suspected viral encephalitis and is commenced on high-dose aciclovir. On the first night of her hospitalisation she has a generalised seizure which is persisting for more than 10 minutes. How would you manage her?

A

Status epilepticus if more than 5 min or no recovery in between seizures.

Resus PLUS

  • benzos (IV loraz/IM midaz)
  • AED (fosphenytoin)
  • correct electrolytes

If refractory
- continuous EEG/cardiac + I+ V + midaz/phenytoin infusion

Later

  • viral enceph management
  • consider other causes
37
Q

A 50 year old woman is hospitalised for IV antibiotics for cellulitis. On the evening of the second day she becomes acutely confused. How would you assess her?

A

= delirium
PDx: infection, concerned about sepsis
DDx: tox/metabolic (eg electrolyte derangement, uraemia), other cause of deranged vitals (DVT/PE), other meds (CNS acting, drug reaction), constipation

1) Primary survey and resus - blood pressure support if necessary
2) Assess and treat underlying cause
2) Delirium management: calm voice, single room, minimise stimuli, orientate, familiar people and voices

38
Q

A 67 year old man presents with moderate shortness of breath. His face is dusky and oedematous and there are multiple dilated veins on his upper body. On CXR he has a large central mass. How would you assess and manage him?

A

SVC syndrome: cerebral oedema, airway obstruction

Resus

  • airway if necessary: intubate, dex
  • stent/radiate if lifethreatening

Assess

  • rule out tamponade (U/S)
  • rule in cancer (lymphoma/lung)
  • CT; noninvasive biopsy if possible otherwise bronch

Manage

  • supportive: PD of POND
  • treat cause
39
Q

A 44 year old woman is receiving chemotherapy for lymphoma. She has been vomiting frequently and her serum potassium is 3.0 mmol/L. How would you manage her?

A

Issues

  • CINV -> hypovolaemia
  • Hypokalaemia -> arrhythmia

Priorities

  • Primary survey and resus - focus on C, including replacing hypoK (slow K if tolerating oral, IV K with NS if not)
  • History and exam re: symptoms of hypoK, fluid status
  • Treat underlying cause (vomiting): fluid replacement, antiemetic (ondansetron, dexamethasone, aprepitant)
  • Monitoring with UECs (twice daily), ECG (if giving K > 10u/hr, ECG abnormalities seen, risk of rebound hyperK)
  • If doesn’t respond to treatment, look for other causes of hypoK (gastric and renal losses)
40
Q

An 82 year old man is admitted to hospital for investigation of falls. He does not pass urine for the next 24 hours. How would you manage him?

A

urinary retention: BPH but rule out spinal cord injury

Mx: Foley’s catheter - duration proportional to duration of symptoms
?TURP

41
Q

A 78 year old woman has with terminal cancer and is expected to die within a few days and is documented as not for resuscitation. She is semiconcious but seems distressed, tachypnoeic and agitated and is making gurgling noises which are distressing to the family. How would you manage this situation?

A

Assessment

  • ask patient
  • check NFR, ACD, enduring guardian
  • ice chips

Management: meds and non-med ways of improving comfort

  • meds: SC analgesia and benzo via driver; antiemetic, glycopyrrolate
  • non-med: 5 senses
  • education, family relationship
42
Q

A 59 year old man is admitted following a myocardial infarction requiring coronary stenting. On the 4th day of hospitalisation he becomes acutely dyspnoeic. How would you assess and manage him?

A

DDx: MI heart consequences( recurrence, arrhythmia, pericarditis, ?rupture), PE, pneumonia

Resus if necessary
Rule out differentials
Supportive care: O2, fluids as necessary
Treat cause

  • **rupture: surgery +/- intraaortic balloon pump temporarily
  • **arrhythmia: amiodarone
43
Q

A 36 year old woman with SLE is hospitalised for investigation of declining renal function. She complains of pleuritic retrosternal chest pain. How would you assess her?

A

DDx: pericarditis, pleuritis (incl pneumonia, PE), MI

resus if necessary
rule out ddx
echo: ?effusion

mx: dialysis if uraemic, NSAIDs if SLE (if no response after 2 weeks, try pred then colchicine)

44
Q

A 63 year old woman has been admitted following a stroke. She develops a urinary tract infection and is treated with intravenous antibiotics. On the 4th day of
treatment she develops severe diarrhoea. How would you assess and manage her?

A

DDx: c diff; infective gastro, ischaemic colitis

  • confirm c diff; rule out ischaemic colitis
  • c diff: give met (or vanc if severe) and change UTI abx
  • supportive care as necessary
45
Q

A 78 year old man has been hospitalised for one week following a stroke complicated by pneumonia. Routine biochemistry shows that his serum creatinine has increased to 280umol/L (60-120) from 110umol/L on admission. How would you manage him?

A

AKI: Cr increased by 1.5x

  • fluid assessment
  • rule out non-pneumonia causes incl drugs
  • monitor closely: UO, daily weights, UECCMP + Ix bloods

MANAGE: 250mL challenge - if transient improvement, patient underloaded so keep giving fluids.

46
Q

A 67 year old woman with iron deficiency anaemia is admitted for a blood transfusion. Two hours after the transfusion commences, she is febrile. How would you assess and manage her?

A

transfusion reaction

  • haemolysis
  • TRALI
  • sepsis
  • FNHR (Dx of EXCLUSION)

Resus
- stop transfusion, contact blood bank

Ix: haemolysis, sepsis screen, CXR

Mx

  • haemolysis: fluid + diuretics; blood if DIC
  • sepsis: abx
  • TRALI: supportive
47
Q

A 57 year old man usually on home haemodialysis presents because his AV fistula has stopped working. He noted 2 hours ago that the usual thrill and bruit are not present. His last dialysis was 2 days ago. How would you manage him?

A

fistula thrombosis/stenosis

  • CKD effects: assess AEIOU to see how much time left and treat if necessary
  • fistula: assess patency with U/S and angiography and repair asap (surgical/radiological thrombectomy OR percutaneous transluminal balloon angioplasty)
  • CVD: optimise risk
48
Q

A 74 year old man has CKD stage 3 with eGFR 58. He is treated for hypertension with ramipril and amlodipine. In recent weeks he has been dizzy and his blood pressure is 98/56 mmHg. His serum potassium is 6.8 mmol/L. How would you manage him?

A

Concerns

  • hypotension
  • hyperkalaemia

1) Primary survey and resus, focus on C
- monitoring incl ecg, uec+cmp
- fluid resus
- stop anti-HTN
- calcium gluconate, glucose + insulin, risonium, frusemide (+bicarb/saline), consider haemodialysis
2) check for ischaemia/tissue hypoxia: assess for stroke/
3) rule out more serious causes of dizziness
4) review CKD mx
5) prevent hyperK recurrence - low K diet, avoid fasting

49
Q

A 20 year old man is found to have microscopic haematuria on a routine employment medical exam. How would you assess him?

A

PDx: exercise, mild glomerulopathy
DDx: trauma, nephrolithiasis, UTI, glomerulonephritis, tumour

Priorities: confirm haematuria and rule out causes
History
- anaemia sx
- exercise/trauma recently
- loin to groin pain
- dysuria, frequency, urgency
- GN risk factors
- tumour risk factors

Exam
- hypertension, oedema

Investigations

  • FBC, Fe studies
  • urine MCS incl casts
  • CT KUB
  • albumin, UEC(, CMP), urine ACS - nephrologist referral if glomerular disease suspected ->
  • consider cystoscopy if risk factors

Management
- treat cause and repeat after 6 weeks

**tumour risk factors
- smoking
- age > 35
- prior macroscopic haematuria
- occupational exposure to benzenes/aromatic amines
heavy no-opioid analgesic use
- uro disease
- recurrent UTIs/symptoms
- pelvic irradiation/alkylating agents
- something

50
Q

An 83 year old woman is admitted following a fall. She becomes acutely confused the following day and is very disruptive in the ward. How would you assess and manage her?

A

Delirium
PDx: head injury
DDx: hypoxia (PE, stroke/brain bleed, MI), tox/metabolic (NGT, electrolytes, uraemia, thyroid, adrenal, parathyroid, meds, drugs), infections, neuro
OTHER: constipation, urinary retention, pain

1) Primary survey and resus
concentrating on C and D -> C: ECG, septic screen, empirical abx if septic, fluid resus if hypotensive
D: NGT (as per hx/BSL), CT brain if not done

2) Thorough hx and examination: events leading up incl treatment, assoc sx, meds, PMHx
Examine for infection, cardioresp event, neuro exam, abdo (?obstruction, constipation)

3) Investigations:
- ECG, BSL, urinalysis
- BSL, UEC, CMP, LFTs, FBC, CRP, TFTs
- septic screen
- CTB, CXR, AXR
- CTPA if ?PE, trops if ?MI

4) Management:
supportive: orientation, reassurance, family, clocks, calendars -> daynight cycle, constant observation, optimise comorbidities/fluids/pain
definitive: treat underlying cause (consider thiamine anyway)

Phase 3 Exams (13 decks)

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