Medical Flashcards
What age do adults need a medical certificate for a driver’s licence?
When do they need to be reviewed?
What are the options if there is concern?
Age 75 and over
- Note holding a licence is NOT a right
10 years until 75
5 years until 80 then 2 years
Questions
- Is anyone concerned?
- Are you less confident about driving
- Have you restricted your habits?
- Do you think you are a safe driver?
Options:
- fully fit, no further Ax
- fit with conditions (can state)
- requires on-road safety test
- needs further Ax e.g specialist or OT
- not medically fit
OT driving Ax
- Off-road: vision, ROM, strength, memory, directional, decisions, rules
- On road Ax if off-road is good
- Send letter to GP who makes decision
- Cost $380-550
What are the common causes of RTAs?
40% loss of control
34% too fast
6% illness or disability
- 1/3 no warning
- 1/3 warning
- 1/3 old age related (2%)
What medications can affect driving?
Benzos
Opiates
Antidepressants
Antipsychotics
Antihistamines
Cold and flu preparations
What are common restrictions for cardio / neuro conditions?
Private / Higher
CVA: 1m AND no residual / NO
TIA: 1m or 3m + I/Mx if multiple / 6m if 1
NM/PD: stop if concern / NO
Cog: stop if concern / NO
Siezure: 12m / NO unless febrile <5
- >1 crash related to seizure = 5 year NO
Vertigo: NO until sufficiently treated
Syncope (known): NO until Ix and Mx
Syncope (x known): 12m / NO unless >5 year without event and on no meds
- can be reduced to 6m with neurology
Minor head: 3hours, 24 if LOC
Serious head: 6m / 12m + neurology Ax
Angina: not if rest or at min (including ?)
MI: 2 / 4 weeks (subject to specialist)
Severe HTN: stop if concern / >220/110
- also if treatment causes postural <bp
Anticoag: stop if uncontrolled
CHF: not if rest or at min / NO
T2DM: No if hypos unaware / insulin needs specialist assessment
Severe mental: NO if impaired (need treatment & observation 6/12 months)
What are options if stopping someone from driving?
- Mobility scooters (x need licence, short distance, 2-7000$/second hand)
- Taxi scheme if difficulty with public Tx
- Free off-peak public Tx supergold card
- Mobility parking, 200m or w/Assists. $45/5year
- Elderly assist / driving miss daisy
How can IBS present?
General
- most common gastro dx GP, 10%
- Intermittent Sx, multifactorial
- Motility + sensation + psychosocial
- May be gut bacteria component, 6x risk after bad gastroenteritis
- Can be: fatigue, n, backache, mood
- Can reduce QOL
- NO structural change, <kg unusual
Who:
- 70% female, <50, lower decile
How is IBS diagnosed?
What are the differentials?
What are the key red flags?
Rome 3 critera
- positive diagnosis, not exclusion
- <50 only need Ix for Ca/IBD if flags
- 3d per month in last 3 months: pain + improve after BO, change in freq and form of stool
- Blood tests PRN: FBC, CPR, coeliac +/- iron. Calpro only if ?IBD
Criteria 6m of
- A - abdominal pain. Food worsens, can be certain foods, menstruation
- B - bloating.
- C - change in bowel habbit
Diffs:
- Coeliac, IBD, lactose intol
- Cancer
- Diverticulitis, colitis
- Gynae: endo, PID, ovarian ca
Flags:
- weight loss, bleeding w/o haemarrhoids, nocturnal, >50 onset, FH IBD/ca/coeliac
- Mass, IDA, inflamm markers
How is IBS managed
Diet:
- Food diary, inc menstruation
- Regular meals, time, chewing, not eating late. 1.5-3L day, avoiding carbonate, caffeine, alcohol
- Triggers: same as gallstone, dairy, sweetener, fruit juice, cabbage, sprouds, corn, onion, legumes
- Fibre advice has changed. If IBS-C, then oats, husk, seeds
- Low FODMAP, referred to dietician
- Fermented foods can help/hinder
- Lastly elimination -> dietician
Meds:
- IBS-D: low fibre diet, loperamide 2mg OD-BD + antispasmodic (Mebeverine 20m before meal) +/- loperamide 45 min before going out
- IBS-C: fibre, laxatives but not lactulose (bloating),
- Pain: peppermint, mebeverine, domperidone, TCAs, SSRI
Who needs dental procedure prophylaxis? How is it prescribed?
W: high risk cardiac conditions
- prosthetic valve
- Rheumatic disease
- Hx endocarditis
- Unrepaired or <6m since repair of congenital disease
- Cardiac shunts
What for:
- manipulation of gingival tissue or root, or perforation of mucosa or tonsillectomy
- NOT for LA inj, xray, appliances, braces
Mx:
- Amox, 2nd clinda / clarithro
- PO 1hr before
- IM 30m before
- IV immediately before
OR 2hr after but less good
How is AF managed? What are the strategies, goals and options?
W: 5% >65
- 5x stroke, 3x CHF, 2x MI/dementia
- Same 4 paroxysmal, y/n Sx, perm
- Rate/rhythm similar outcome/QOL
Urgent (d/w cardio)
- <48hr symptomatic
- unstable
Hx:
- ?PE, >Thyroid, ETOH, cardiac BG
Mx:
- ALL -> ECHO
- CHA(2 for >74),DS (2 stroke), VA (1 for 65-74), Sc (F = 1)
- HASBLED: BP, C/LD, stroke, bleed, INR, Age >65, drugs or ETOH. xfalls
- Rate/rhythm
- Anticoag
Rhythm if:
- Symptomatic parox, CHF, <48hr
Rate
- Target <110, <90 if LVSD or if Sx
- Use bb + dilt before digoxin / Amio
Refer:
- Ongoing sx or poor control HR
- Brady not improving after x Rx
- Failure or other concerns
- Rhythm control
CHF
W: 10% >70, increasing with aging pop, >kg, T2DM, IHD
- MAPAS <age, hospx2, deathx4
- 50% 5-year survival
D:
- HFrEF: <50%
- HFpEF: evidence of structural disease, diastolic dysfunction
1: No limit
2. Slight, SOB w ordinary activity
3. Mod, SOB w less than normal
4. Severe, Any activity or at rest
Ix:
- ECG: LBB, poor R progression (V1 -> 6, ischaemic, AF
- BNP: > in AF, COPD, LVH. < in obesity, <thyroid, diuretics/ACE
- ECHO: assume HFrEF b4 result, should repeat after stable on Rx
Mx:
- New? FU 2x/week
- Non pharm: Ex, <2g Na, <kg, 1.5-2L fluid, x smoking, vaccines
- Fluid -> Frusi or thiazide if SE
- ACE immediately. ARB if SE
- BB once fluid overload gone
- Still Sx -> ARNI, stop ACE/ARB
- Still Sx -> add spironalactone
HFpEF
- Spiro, SGLT2 if SA, ARNI
+/-
- AF: digoxin, anticoagulation
- Anaemia: IV ferrinject
- T2DM: SGLT2
+/- device
- Refer: persistent <40%, valvular, syncope, LBBB, arrest
Frusi
- Aim 1kg/day loss to dry weight
ARB/ACE
- Not if BP <100, K >5.5, GFR <30
- Check U&E 1w, then 3mly
- Stop/advice if Cr by >25%
Spiro:
- Same r/e bloods as ACE/ARB
- Eplerenone on SA if manboobs
Entresto:
- X ACE 36hr, 24hr ARB (angio)
- Start med dose. Low: frail, CKD
- SA: Class II-IV, <35% or a/w ECHO + on other suitable meds
CKD
W: 30% by 70, higher in pasifika
- 50% dialysis = T2DM
- >50% dialysis MAPAS
Cx: CVD +++
Sx: 90% decline before symps
Mx: screen 1-2yrly if at risk
Def: any change, GFR <60, >3m
g1 >90
g2: mild 60-89: FU annually
g3a: mild-mod 45-59: FU 3-6m
g3b: mod-sev 30-44: FU 3-6m
g4: 15-29 (CVD 15%): FU 1-3m
g5: <15
Decline (not age) = >5/year
- If <60m repeat within 14d
- If reduction >20% ?AKI, refer
ACR (PCR if tube dx/myeloma)
microalbumin: 3-30
macro: >30 (FU 1-3monthly)
-> raised? repeat so 3x in 3m
- > UTI, fever, period, HF, Ex, Mx
Further Ix:
- USS, FBC/CRP/HbA1c/Lipid
- Dip: blood? request MSU ?cast
- Others depending on idea
Mx:
- BMI: <30, ideal <25 (5kg = 5BP)
- 3hr/wk mod ex, 90min intense
- 2g salt/day, med diet, fish
- 10SD ETOH/wk + 2 free days
- ACE/ARB then CCB. Titrate 1st
- DM control (> risk hypo G4/5)
STOP in acute illness: SADMANS
Sulphonylurea, ACE, Diuretics, Metformin, ARB, NSAID, SGLT2
Refer:
- <30, persistent ACR >30
- Diabetes <45
- GFR decrease 20%, >15 frm 60
- 5yr risk failure >3-5%
- Suspected intrinsic cause
- Haematuria pathway
- CKD + HTN despite 3x meds
Gout
KP
- discuss allo at FIRST attack
- lifestyle alone NOT enough
- 40% have n urate in flare
- Aspiration if susp other cause
- Start allo: 2x falre, tophi, GFR <60, stones, urate >0.54
- monthly urate then 6-12m
- avoid probenacid with stones
- avoid febuxostat in liver issue
- Losartan and CCB lower urate
Risks:
- age, genetics, MAPAS, M, HTN, obesity, diuretics, red meat/sea/ETOH/sweet drink
Mx:
Naproxen: 750 mg STAT, 500 mg 8hr, then 250 mg every eight hours until the flare has settled
Eating disorders
3% AN, 12% BN, 47% binge
- 80% AN are female, 20% M
Restless legs / burning feet
Restless legs:
- Increases with age, earlier onset likely more severe
- not connected to PD. Often FH
Sx: urge to move limbs, tingling, sensory sx triggered by rest, relaxation, sleep, better with movement. Not totally relieved by movement.
Dx:
- IDA, preg, thyroid, RA, CKD, peipheral neuropathy, meds
Mx:
- Sleep hygeine, exercises b4 bed
- Distraction with reading
- Roprinolol/ldopa/gabapentin. Can make more severe
Burning feet:
- >40, burning, mostly soles
- Sensory exam may be abn
Ix: HbA1c, LFT (ETOH), myeloma, Iron, B12, folate, TFT, HIV if risk
Mx: avoid tight socks/shoes, avoid heat, paracetamol +/- capsacicin, TCAs/neuro if worse
When to start Carbimazole? What dose?
Request endo clinic
Manage as hyperthyroidism if:
- TSH persistently <0.1
- Symptomatic
- FT4 or FT3 above the reference range
Subclinical (n FT4 and FT3): 2.5 to 5 mg OD
Mild (FT4 or FT3 <2x ULN): 5 to 10 mg OD
Moderate (FT4 or FT3 2-3x ULN): 10 mg BD
Severe (FT4 of FT3 >3x ULN) or tachy, rapid <kg): 15 mg BD + beta blocker
Need FBC and LFT prior
Agranulocytosis risk (sign consent form)
- 1/200-1/500
- Stop taking carbimazole and seek medical attention straight away
- Sx: fever, flu-like symptoms, sore throat, mouth ulcers.
- Urgent, same day FBC. Low neutrophil count -> acute general medicine
Mx
- Repeat 4-6/52 TFT whilst a/w clinic
- Reduce the dose if FT3 or FT4 HALF
- Maintenance dose is generally 2.5 to 10 mg a day
- 50% relapse -> radioiodine / surgery
- Not resolving -> ?Toxic goitre
- Propylthiouracil an alternative - discuss with endo
Thyroid eye disease
Severe -> acute ophth and non-acute endo
- any reduction in corrected vision
- constant double vision
- severe swelling of lids, proptosis or retraction
- altered colour perception
Moderate -> non acute
- painful eyes, some swelling, moderate proptosis/retraction, diplopia
Mild -> non-acute
- Gritty, mild swelling, no visual disturbance
Opiate prescribing
PO:SC morphine = 2:1
PO Morphine: Oxy = 1.5 - 2:1
PO Tramadol/codeine/dihydro:Morphine = 10:1
SC Morphine:Oxy = 1:1
With PRN put amount to dispense, otherwise pharmacists will give maximum. Regular 30 days
Fentanyl patch
12.5 = <60mg morphine
25 = 60-134
50 = 130-220
Methadone
- half life 30 hours, difficult to titrate
- takes 5-7 days to reach steady state
- can cause QT issues
- Starting dose 2.5-5mg BD
Adjuvant:
- Neuropathic: TCA/GABA
- Bone pain: NSAID, bisphosphonate
- Spasm: diazepam, baclofen
- Smooth muscule spasm: buscopan
- Bladder pain -> catheter
- Pressure (brain, liver, bowel): dex
SE:
1. Constipation - laxsol up to 3BD. Not effective then lax-sachet. If innefective 24-48hr -> PR
- Empty rectum -> dantron + polaxamer b4 bed
- Soft -> 2x bisacodyl suppos.
- Hard -> 1x bisacodyl and 1x glycerine suppos.
- Nausea
- Haloperidol 0.5-1mg nocte - BD (chemorecept)
- Metoclopramide 30min b4 food (motility)
- Domperidone (lower SEs but only oral)
- Cyclizine (vestibular but SE of constipation)
- Ondansetron not recommended in palliative
Hormone Testing
- What are the functions in men and women
- What are the reference ranges
LH/FSH (CHECK D2-4)
W: GNRH -> anterior pituitary
F:
1. Follicle growth
2. Andro (oestrogen by aromatase)
3. Mid-cycle LH surge -> ovulation
M:
1. FSH -> Sertoli cells -> Sperm
2. LH -> Leydig cells -> Testosterone
Phase FSH (IU/L) LH (IU/L)
Early follicular 3 - 10 2 - 8
Mid-cycle peak 4 - 25 10 - 75
Post-menopausal > 20 > 15
Pregnancy < 1 2 - 9
Oestradiol
- FIRST part of cycle (follicular phase)
- Males: sperm maturation
- LOW if on oestrogen contraception
- VARIES if on HRT
Early follicular < 300
Ovulatory surge < 500 - 3000
Luteal surge 100 - 1400
Post-menopausal < 200
Progesterone (CHECK DAY 21)
- SECOND phase (luteal)
- If pregnancy -> HCG maintains prog
- Placenta produces from 12 weeks
- Decrease after delivery and breast
- LOW post menopause
- Males: converted to testosterone
Detecting ovulation – measured on day 20 – 23 of a normal 28 day cycle:
The reference range for progesterone in adult males is < 1 nmol/L. 1
0 – 6 nmol/L ovulation unlikely
7 – 25 nmol/L ovulation possible
> 25 nmol/L ovulation likely
Prolactin
- Prolactinoma most common pit ca
- Usually with < test / oes levels
- Micro more common
- Macro present w headache/visual
- DO IN AFTERNOON WHEN WELL. X Pysch meds, opiates, dopa agonists
- If raised, check smaller prolactin - if normal, other is probably artefact
Testosterone - check in morning
- If symptoms: libido, no am erection
- >15 -> no action
- lower -> recheck -> LH
- If low -> add PRL (FSH only fertility)
Hormone testing
- When indicated?
W:
- primary or secondary amen
- hypogonadism
- confirming pregnancy / fertility
Delayed puberty
W: weight, diet, exercise, pit, congen
SX:
- No breast development by 14
- No periods by 16
- 16 in males
IX: TFT, FSH/LH, Oes/test, PRL
- Low eos, low LH: hypothalamic
- <LH/FSH: hypogonadotro (Kallman)
- >High LH/FSH: hypergonad (Turner)
- >Testosterone: PCOS
- Normal? Anatomical
- Males: low FSH/LH in constitutional
MX: Refer endocrine
Precocious
W: G<8, B<9, rarer
Refer ANY suspected -> result in impaired final height
Secondary amenorrhoea
W: Mostly hypothalamic, PCOS, ovary
IX: FHS/LH, Oes +/- PRL, TSH
- FSH >20, low oes: premature
- Low LH, oes: hypothalamic
Gynaecomastia
- Hard, concentric ring around nipple
- Oestrogen > testosterone
- >meds (TCA, metronidazole, spiro, CCB, cimetidine, cirrhosis)
- IX: test, LH if low, oes, hCG (ca)
