Med pre-2017 Flashcards
A 65 year old woman suffers an undisplaced fracture of the radius after falling down when intoxicated. Her alcohol is at least 60g/day. What would you advise her regarding her alcohol intake?
5As: ask, assess, advise, assist, arrange f/u
- assess: alcohol dependence (AUDIT), complications, underlying risk factors
- advise (educate): normal consumption, consequences
- assist: non pharm, pharm, multidisc
A 72 year old man presents with a red, painful, swollen left 1st metatarsalphalangeal joint. How would you assess and manage him?
- ddx: CPPD, septic arthritis, others less likely
- ask for risk factors (incl sexual activity?)
- determine pattern
- bloods, xray, MCS
Management
- non-pharm: ed, diet, med review
- pharm: initially NSAIDs/colchicine/pred; then allopurinol +/- uricosuric agent to <6mg/dL (nontophi)
An 18 year old man is found to have proteinuria (++ on dipstick) during an insurance medical examination. There is no significant past history or abnormal physical findings. How would you assess him?
IF REAL, probs transient/physiological BUT rule out glomerular disease (MM really unlikely)
a) if suspicious history, rule out with a negative MCS and dipstick
b) if ordinary history, rule out with a negative dipstick
- -> if either positive, rule out orthostatic proteinuria then full on investigation
A 70 year old man with type II diabetes presents complaining of an episode of facial asymmetry and weakness which lasted 5 minutes. How would you assess and manage him?
risk of stroke 5% in next 48 hours, 10% in 2 weeks
priorities
- resus if necessary
- confirm dx
- find source: carotid Dopplers, ECG, echo
Mx
- ?thrombolysis if disabling
- aspirin
- treat cause
- RF modification
A 70 year old man presents with several weeks of back pain and progressive leg weakness over 3 days associated with urinary urgency. There is a T10 sensory level deficit and he is in urinary retention. How would you assess and manage him?
PDx: malignancy
DDx: disc herniation, vertebral fractures, infection (discitis, spinal abscess)
priorities
- confirm PDx incl neuro deficits (?cauda equina)
- assess degree of compression and spinal stability (SINS)
- assess extent of disease
- assess fitness for surgery
- deal with asap stuff
mx
- supportive
- steroids
- surg +/- rtx: decompressive laminectomy
- systemic tx for underlying cancer
A 70 year old woman complains of increasing tiredness. Her Hb is 98 g/dL (115-165) with low MCV and MCH. How would you manage her?
microcytic anaemia = TAILS
- crc, UG bleed, intake, chronic disease
mx
- iron supplementation
- treat cause
iron def: koilonychia, glossitis, angular cheilitis, tin hair
A 43 year old woman asks about whether she should be investigated because her grandfather had bowel cancer. What would you advise her?
assess for
- symptoms
- mod risk: 1 fam diagnosed young (<55yo), 2 or more on the same side diagnosed at any age
- high risk: suspected HNPCC/FAP (more fam), identified HNPCC or FAP gene in the family
mx
- normal: FOBT starting at 50
- mod: scopes at 50 or 10 years younger than youngest cancer
- high: scopes yearly from 15yo (FAP) or 25 (HNPCC) PLUS genetics referral
HNPCC - genetic testing done if Amsterdam (321) criteria fulfilled
A 70 year old woman is admitted with hypertension and cardiac failure. She is commenced on indapamide (a thiazide-like diuretic). Her admission is complicated by a urinary tract infection. She is treated with amoxicillin as she had a previous drug reaction to cotrimoxazole (sulphamethoxazole + trimethoprim). On the third day of amoxicillin treatment she becomes febrile and develops a generalised maculopapular rash. How would you assess and manage her?
- drug reaction: likely mobilliform, but could be anaphylaxis, DiHS/AGEP/SJS/TEN
- viral exanthem
Ax
time course
worrying sx: erythroderma, high fever, blistering, facial oedema, mucositis, skin tenderness
Mx
stop drug
supportive care: topical steroids and PO antihist
education
A 60 year old man is admitted to hospital with an acute exacerbation with COPD. Within hours of his admission, the nursing staff report that he has become drowsy and difficult to rouse. How would you assess and manage him?
resus: (monitor incl ECG)
B - O2 via biPAP, steroids, bronchodilators
C - get ABG
treat exac cause (INFECTIONS, fluid overload, rapid AF, PE, pneumothorax)
improve COPD mx
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?
assess obesity
assess reasons for being overweight
address reasons
- education
- motivational interviewing
- psych
pharm is terrible, refer to specialist bariatric unit if BMI > 40 (or >35 with other comorbidities)
A 48 year old man complains of headaches. Physical examination is unremarkable except for his BP which is 175/100 mmHg. How would you assess and manage him?
Priorities
- rule out urgency (encephalopathic, CCF)
- look for end-organ damage: head, heart, kidneys, peripheries, eyes
- rule out secondary cause of HTN
- rule out other cause of headache
- reduce BP gradually (to 160/110 over 2-8 hours (first 2 hours do not reduce by more than 25%) and then keep at that for a day, then reduce lower if necessary)
Management
- quiet room
- transdermal amlodipine/GTN
IF URGENT (IV) - sodium nitroprusside/clonidine
A 70 year old woman notices yellow discoloration of her eyes over three weeks. She has lost 4 kg but has not had any abdominal pain. How would you assess her?
Painless jaundice
PDx: pancreatic cancer
DDx: duodenal, ampullary, cholangiocarcinoma, other causes of jaundice (haemolysis, chronic liver disease)
Assessment
- cancer sx
- obstructive jaundice sx
- risk factors for chronic liver disease/haemolysis
- surgery risk
- bloods: tumour marker (Ca 19-9, LFTs, preop bloods)
- imaging: abdo U/S, CT abdo, consider ERCP (+biopsy) if CT abdo equivocal
Management: MDT
- stage
- surgical resection (Whipple’s/distal pancreatectomy) +/- chemoradiotherapy
A 59 year old man who was admitted two nights previously after being hit by a car is noted to be sweaty, tachycardic, tremulous and agitated. He has a history of heavy alcohol use. How would you assess and manage him?
Resus if necessary
- A: secure if necessary, benzos (diaz every 2 hours if DTs)
- C: clonidine
Assess
- confirm dx and rule out DDx (head trauma, CV/resp event, infection)
Mx
- non-pharm: quiet place, verbal orientation, reassurance
- supportive: thiamine+glucose, other deficiencies, fluids, nutrition, frequent monitoring
- pharm: benzos (titrate to score)
A 68 year old man has been in hospital for 6 days receiving intravenous antibiotics for prostatitis, which need to continue for another 4 days. You are the ‘after-hours’ intern and the nursing staff request you resite his cannula which “tissued”. The patient however is quite unhappy that this is the 5th attempt at a cannula today and does not want another cannula. How would you manage this situation?
Priorities
- confirm tissueing
- understand patient’s perspective
- examine indication for IV: oral therapy if sensitivities available
- explain alternatives
- insert IVC / get anaesthetics registrar
A 52 year old woman is concerned about developing Alzheimer’s disease as both her mother and her maternal grandmother developed dementia in their late 60’s. What would you advise her?
Priorities
- look for dementia
- look for risk factors/reversible causes (CVD, PD, depression, B12, thyroid, head injury, drugs)
- explain risk: familial vs sporadic (25-50% in immediate family member); counsel about CVD risk, regular screening if worried
- further testing if symptomatic
- consider genetic testing if fhx of early onset dementia
***domains:
memory
language
executive function: coping with unexpected events
complex attention: balancing a checkbook, spatial ability
social
behaviour
