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Hark and Paul's clinical review > Derm, Gen med and Long cases > Flashcards

Derm, Gen med and Long cases Flashcards

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1
Q

Chronic Kidney Disease history - GO!

A

P: Nocturia, Pruritis, Lethargy
R: Diabetes, Glomerulonephritis, Hypertension, Polycystic Kidneys, Reflux nephropathy, Recurrent UTIs
I: Cr & eGFR, Urine albumin: creatinine ratio, Ultrasound, renal biopsy
C: Anaemia, Acidosis, Renal Osteodystrophy, Electrolyte disturbance, Fluid overload, Uraemia (Encephalopathy, Pericarditis, Bleeding), Peripheral neuropathy
M: Salt restriction, Fluid restriction, Erythropoietin Stimulating Agents, Sodium Bicarbonate, Ca/Vitamin D, Calcitriol, Phosphate binders, Parathyroidectomy, Resonium, Diuretics, HTN & Hyperlipidaemia
- Dialysis (Type, Access, UF, IBW, UO, Hypotension)

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2
Q

Renal Transplant history - GO!

A
  • Cause of ESKD
  • Bridging with Dialysis
  • Type of Transplant (living vs. cadaveric)
  • Degree of HLA matching
  • CMV/EBV status
  • Immediate Complications
  • Rejection episodes
  • Graft biopsies
  • Chronic Allograft Nephropathy
  • Transplant GLomerulonephritis or Renal artery stenosis
  • Immunosuppressive regimen & SEs e.g. Infections (BK nephropathy), Malignancy, CNI nephrotoxiity, HTN, NODAT, Cushing’s syndrome
  • Drug Level Monitoring
  • Prophylactic Regimen
  • Bone Health
  • Dermatology Clinic
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3
Q

Ischaemic Heart Disease history - GO!

A

P: Angina, PND, Orthopnoea, Oedema, Syncope, Palpitations, NYHA Class
R: Male Sex, Previous IHD, Smoking, Diabetes, HTN, Hyperlipidaemia, Family history, OCP
I: ECG, TTE, Stress test, CTCA, Cardiac MRI, COronary Angiogram, Cardiac Biopsy
C: Angina, ACS, Arrhythmias, Syncope, Cardiac Arrest, Cardiac Failure
M: Statin, Aspirin, ACEi/ARB, Beta-blocker.
-Hypertension Control.
-Cardiac Rehabilitation Program.
-Percutaneous Coronary Intervention or CABG

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4
Q

Heart Failure history - GO!

A

P: Angina, PND, Orthopnoea, Oedema, Syncope, Palpitations, NYHA Class
R: Arrhythmias, ACS/MI, Non-adherence with medications/fluid restriction, Anaemia, Infection/Sepsis, PE, Thyrotoxicosis. Aetiology includes Valvular diseases, IHD, Dilated Cardiomyopathy (alcohol, connective tissue, drugs), Pulmonary hypertension
I: BNP, ECG, TTE, Cardiac MRI, Coronary Angiogram, Cardiac Biopsy, RHC, 6MW
C: Angina, ACS, Arrhythmias, Syncope, Cardiac Arrest
M: Fluid/Salt restriction/Daily Weights. Statin, Aspirin, ACEi/ARB/ARNI, Beta-blocker, Diuretics (Loop, Mineralocorticoid), Ivabradine if sinus, Digoxin, Inotropes. CRT, AICD, LVAD. Cardiac Rehabilitation.

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5
Q

Heart Transplant history - GO!

A
  • Cause of ESHF
  • Bridging with Mechanical Cardiac Support
  • HLA Match
  • CMV/EBV Status
  • Immediate Complications
  • Rejection Episodes
  • Surveillance BIopsies
  • Surveillance Coronary Angiography
  • Coronary Allograft Vasculopathy
  • Immunosuppressive Regimen & SEs
  • Drug Level Monitoring
  • Prophylatic Regimen
  • Bone Health
  • Dermatology Clinic
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6
Q

Infective Endocarditis history - GO!

A

P: Fever, Rash, Haematuria, PND, Orthopnoea, Oedema
R: IVDU, Rheumatic fever, Recent Dental/Endoscopic procedures, Colonic cancer
I: Blood Cultures, TTE, TOE
C: Valve dysfunction, Paravalvular abscess, Embolic phenomenon, Heart failure
M: IV ABx, PICC line, Surgery, Prophylaxis measure

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7
Q

Diabetes Mellitus - GO!

A

P: Polyuria, Polydipsia, Nocturia.
I: BGL, OGTT, HBA1C, Urine albumin: creatinine ratio
C: Macrovascular (CVA, IHD, PVD), Microvascular (Retinopathy, Nephropathy, Neuropathy), Autonomic (gastroparesis, Postural hypotension).
M:
-BGL Monitoring
-Driving
-Diabetes Educator, Optometrist, Podiatrist (Footwear, Orthotics)
-Diet, Exercise
-OHGA
-Insulin (Type, Insulin Pump, Injection administration, Lipohypertrophy, Carbohydrate counting, Hypoglycaemic episodes, Hypoglycaemic management plan)

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8
Q

Bone Marrow Transplant history - GO!

A
  • Indication
  • Type of Transplant (Autologous vs. Allogeneic)
  • HLA/ABO Matching, CMV status if Allogeneic
  • Source of Stem Cells (Bone marrow, Peripheral blood, Cord blood)
  • Conditioning Regimen
  • Immunosuppressive Regimen (Allogeneic)
  • Complications including INfections, Graft Failure, GVHD (Allogeneic), Hyposplenism (Allogeneic), Conditioning Regimen (Infection, Malignancy, Infertility, Peripheral Neuropathy), Relapse of Original Condition
  • Monitoring including Chimerism Level, Bone marrow biopsy
  • Management including Donor Lymphocyte Infusion, Transfusion support, Prophylaxis (Penicillin, Bactrim, Antivirals, Antifungals)
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9
Q

Haemophilia history - GO!

A

P: Bleeding, Haemarthroses, Arthropathy,
I: Genetics, Factor levels, Inhibitors (Bethesda assay)
C: Arthropathy, Bleeding, Inhibitor Formation, Transmitted Infections (Hepatitis, HIV)
M: Transfusion Support, Factor Replacement, Bypass Agents (Prothrombin Complex Concentrate, Recombinant Factor VIIa, FEIBA), Emicizumab, Antifibinolytics (Tranexamic acid, Aminocaproic acid), Prophylaxis (with coagulation factor concentrates from early childhood to prevent end stage joint damage)

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10
Q

Leukaemia history - GO!

A

P: Tiredness, Dyspnoea, Infection, Bleeding, Bruising, B-symptoms (Fever, Night Sweats, Weight Loss), Lymphadenopathy
R: Previous Chemotherapy or Immunosuppression, Myelodysplastic Syndrome
I: FBC, Blood Film, Flow Cytometry, Bone Marrow Biopsy, Lymph Node Biopsy, Stagin (lumbar Puncture, CT Neck/Chest/Abdomen/Pelvis).
Immunophenotyping, Cytogenetics.
C: Infections, Bleeding, DIC, Hyperleukocytosis, Treatment Complications (Neutropaenia, Tumour Lysis Syndrome)
M: Antibiotics, Transfusion Support, Chemotehrapy, Stem Cell Transplant

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11
Q

Lymphoma history - GO!

A

P: Tiredness, Dyspnoea, Infection, Bleeding, Bruising, B-symptoms (Fever, Night Sweats, Weight Loss), Lymphadenopathy
R: Previous Chemotherapy or Immunosuppression
I: FBC, Blood Film, Flow Cytometry, Lymph Node Biopsy, Staging (Bone Marrow Biopsy, CT Neck/Chest/Abdomen/Pelvis).
Immunophenotyping, Cytogenetics.
C: Infections, Cytopaenias, Treatment Complications (Infection, Radiation pneumonitis, Secondary malignancies, Fertility).
M: Radiotherapy, Hodgkin’s (ABVD, BEACOPP), Non-Hodgkins (RCHOP), Stem Cell Transplant

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12
Q

Bronchiectasis history - GO!

A

P: Haemoptysis, Productive cough
R: Cystic Fibrosis, Childhood infections, Hypogammaglobulinaemia, ABPA, Primary Ciliary Dyskinesia, Bronchial Adenoma
I: Sputum m/c/s (colonisation), Immunoglobulin, CF tests, CT Chest, Bronchoscopy
C: Haemoptysis, Empyema, Lung abscess, Cerebral abscess, Amyloidosis
M: Sputum Clearance (Physiotherapy, Postural drainage, Flutter valve), Antibiotics, nebulised Antibiotics, Vaccinations, Bronchodilators. Specific Treatments (IVIG, Bronchial artery embolisation, Surgery).

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13
Q

COPD history - GO!

A

P: MMRC Dyspnoea Score
R: Smoking, Occupational exposures, Dust exposures, A1-AT deficiency
I: Spirometry (GOLD classification), Pulmonary Function Tests, Sputum m/c/s (colonisation), CXR< CT Chest
C: Respiratory Failure, Exacerbations, Cor Pulmonale
M: Smoking cessation, Pulmonary rehabilitation, Bronchodilators, Inhaled Steroids, Antibiotics, NIV, Vaccinations, Home oxygen

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14
Q

Pulmonary Hypertension history - GO!

A

P: Dyspnoea (NYHA Class), Chest pain, Syncope, Oedema, Exercise Tolerance.
R: Idiopathic, Left Heart Disease, Lung Disease/Hypoxia, CTEPH, Miscellaneous (connective tissue, congenital heart disease, HIV)
I: ABG, PFTs, CXR, HRCT. V/Q, CTPA, ECG, TTE, 6MWT
C: Respiratory Failure, Right Heart Failure
M: Oxygen, Diuretics, Idiopathic (Bosentan, Prostacyclin, Sildenafil, Riociguat), COPD (Bronchodilators, Steroids), PE (Anticoagulation, Embolectomy)

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15
Q

Cystic Fibrosis history - GO!

A

P: Meconium Ileus, Recurrent respiratory infections, Haemoptysis, Dyspnoea, Sinusitis, Diarrhoea, Steatorrhoea
I: Sweat Chloride Test, Genetic Testing (G551D or DeltaF508 Homozygosity), Sputum m/c/s (colonisation incl. Burkholderia, Mycobacterium Abscessus), LFTs, PFTs (FEV1) CXR, CT Chest.
C: Lungs (Bronchiectasis, Pulmonary hypertension, Respiratory failure, Pneumothorax, ABPA, Sinusitis), Gastrointestinal (Meconium ileus, Distal inetestinal obstruction syndrome, Pancreatic Exocrine & Endocrine Insufficiency incl. DM, Chronic liver disease), Infertility, Osteoporosis, Salt Crises.
M: Vaccinations, PT, Pulmonary Rehabilitation, ABx, Nebulised ABx, Macrolides, Dornase Alfa, Hypertonic Saline, Gene Specific Therapy (Lumacaftor, Ivacaftor), Pancreatic Enzyme Supplementation, Sperm Harvesting, Lung Transplant

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16
Q

Tuberculosis history - GO!

A

P: Productive Cough, Haemoptysis, Weight loss, Fevers.
R: Immunosuppression (HIV), Endemic Country, Sick Contacts
I: Sputum m/c/s/ for AFB & Z-N stain, Mantoux, IGRA, Blood cultures, CXR, CT Chest, Bronchoscopy, BAL, Lymph node biopsies, HIV, Resistance Profiles
C: Pulmonary, Miliary, Meningitis
M: Isoniazid, Rifampicin, Ethambutol, Pyrazinamide, Latent TB (Isoniazid)

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17
Q

Lung Transplant history - GO!

A
  • Indication
  • Type of Procedure
  • Immediate Complications
  • HLA/ABO Match
  • CMV/EBV Status
  • Rejection Episodes
  • Chronic Lung Allograft Dysfunction (CLAD)
  • Pulmonary Function Tests (FEV1)
  • Surveillance Bronchoscopies/Biopsies
  • Immunosuppressive Regimen/SEs
  • Drug Level Monitoring
  • Prophylactic Regimen
  • GORD Management
  • Bone Health
  • Dermatology Clinic
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18
Q

Inflammatory Bowel Disease history - GO!

A

P: Weight loss, Altered Bowel Habits, Diarrhoea, Melena, PR Bleeding, Fevers, Abdominal Pain, Arthralgias
I: Stool m/c/s, LFTs, Colonoscopies, Pill Cam, CT Abdomen/Pelvis, FOBT.
C: Fissure, Fistulas, Abscesses, Obstruction, Perforation, Haemorrhage, Carcinoma, Episcleritis, Cirrhosis/PSC, Amyloidosis, Arthropathy, Renal stones
M: Malignancy Screening with Colonoscopy/Biopsy, Mesalazine Enemas, Sulfasalazine/Mesalazine, Azathioprine/6-MP, Biologics (Vedolizumab, TNF Inhibitors), Surgery, Acute Exacerbations (IV Steroids, IV ABx).

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19
Q

Chronic Liver Disease history - GO!

A

P: Pruritis, Jaundice, Abdominal distension/pain, Haematemesis, Child Pugh Score
R: NAFLD, Hepatitis, IVDU, Transfusions, Tattoos, Alcohol, Drugs, Autoimmune/Genetic (AIH/Wilson’s Disease, Haemochromatosis, PBC/PSC, A1AT, CF), RHF/TR, Budd-Chiari Syndrome
I: LFTs, Serology, US, Fibroscan, Liver Biopsy, Paracentesis, MRCP/ERCP
C: Encephalopathy, Oesophageal Varices, Gastric Varices, Hepatocellular Carcinoma, Caput Medusae, Portal Hypertension (Splenomegaly, Thrombocytopaenia, Ascites, SBP), Coagulopathy, Hepatorenal Syndrome, Anorectal Varices.
M: Fluid/Salt Restriction, Lactulose/Rifaximin, Variceal Ligation/Beta-blockade, Diuretics, Paracentesis, Prophylactic ABx, HCC Screening, TIPSS, Liver Transplantation

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20
Q

Viral Hepatitis history - GO!

A

R: IVDU, Blood transfusions, Sexual transmission, Tattoos, Mother-Child
I: Hepatitis Serology, LFTs, HCC Screening, Genotype Testing, Fibroscan, Abdominal Ultrasound
C: Cirrhosis, HCC, Cryoglobulinaemia, Glomerulonephritis
M: HBV (Interferon, Lamivudine, Tenofovir), HCV (Direct Acting Antivirals e.g. Sofosbuvir), Liver Transplant

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21
Q

Liver Transplantation history - GO!

A
  • Indication
  • Type of Procedure
  • ABO/HLA Matching
  • CMV/EBV Status
  • Immediate Complications
  • Rejection Episodes
  • Biopsies, LFTs, Fibroscan, Abdominal Ultrasound
  • Immunosuppressive Regimen & SEs
  • Drug Level Monitoring
  • Prophylactic Regimen
  • Bone Health
  • Dermatology Clinic
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22
Q

HIV history - GO!

A

P: Seroconversion Illness, Fevers, Night Sweats, Weight Loss, Dyspnoea, Cough, Diarrhoea, Peripheral Neuropathy, AIDS Defining Illnesses (Kaposi, CMV, Toxoplasmosis, Oesophageal Candidiasis, PJP, NHL, MAC, TB, Oral Hairy Leukoplakia, Castleman Disease)
R: IVDU, Sexual Intercourse, Homosexuality, Blood Products
I: CD4 Count including Nadir, Viral Load, Genotype, Resistance Testing, HLAB5701, Hepatitis Serology, Syphilis/Other STI testing.
C: AIDS Defining Illnesses, IRIS, Medication SEs, Depression, Drug Holidays
M: HAART Regimen, Prophylaxis, Cardiovascular Risk Factor Modifaction (Smoking cessation, Weight Loss, Hyperlipidaemia Treatment), Vaccinations, Sexual Health Screening, PrEP, PeP

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23
Q

Multiple Sclerosis history - GO!

A

P: Spastic paraparesis, Paraesthesiae, Visual disturbance, Urinary or Faecal symptoms
R: Heat (Uhthoff’s phenomenon)< Exercise, Fever/Infection
I: MRI Brain/Spinal Cord, Visual evoked potentials, Auditory evoked potentials, LP/CSF.
C: Disease (Bladder dysfunction, Spasticity, Muscle spasms), Treatment (PML).
M: IV Methylprednisolone, Plasmapharesis, IVIG, Interferon, Glatiramer acetate, Natalizumab, Mitoxantrone, Ocrelizumab, Rituximab, Glatiramer/Dimethyl fumarate safe in pregnancy. Symptoms (Baclofen for spasticity, Antiepileptics for Spasm etc).

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24
Q

Myasthenia Gravis history - GO!

A

P: Ocular (diplopia, ptosis), Bulbar (dysphagia, dysarthria, difficulty chewing), Limb girdle (proximal muscle weakness), Difficulty Anaesthesia, Pneumonia
R: Medications (beta blockers, calcium channel blockers, quinidine, procainamide, antibiotics e.g. gentamicin), Sleep deprivation, Anxiety/Stress, Alcohol
I: Acetylcholine receptor antibodies, MuSK antibodies, Electromyogram, Thymoma (CXR, CT Chest, MRI), Respiratory function tests.
C: Respiratory involvement, Difficult anaesthesia
M: Crisis (IVIG, Plasmapharesis), Respiratory support, Acetylcholinesterase inhibitors (Pyridostigmine), Steroids, Immunosuppressants, Thymectomy

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25
Motor Neurone Disease history - GO!
P: Muscle weakness/atrophy/spasm, Limb onset ALS (difficulty walking/running), Bulbar onset ALS (dysphagia, speech difficulties), Respiratory involvement I: EMG, NCS, MRI, PFTs C: Dementia, Aspiration, Respiratory Failure M: Medications (Riluzole), Respiratory Support (NIV), Physical Therapy, Nutrition, End of Life Care
26
Stroke history - GO!
P: Hemiparesis, Aphasia, Visual disturbance etc. R: Hypertension, Smoking, Diabetes, Hyperlipidaemia, AF, Vasculitis I: CT/MRI Brain, Carotid ultrasound, TTE/TOE, BGLs/Lipid profile, Connective tissue (ANA, Anti-Cardiolipin, Thrombophilia screen). C: Dysphagia, Pressure sores, Deconditioning, Aphasia M: Ischaemic (Thrombolysis, Clot retrieval), Haemorrhagic (Surgery), Aspirin, Statin, Stroke Rehabilitation
27
Parkinson's Disease history - GO!
P: Tremor, Bradykinesia, Rigidity, Postural instability, Cognitive impairment, Psychosis, Falls R: Vascular (Strokes) I: CT Brain (exclude Normal Pressure Hydrocephalus), SPECT for dopamine activity in basal ganglia C: Cognitive dysfunction, Mood disturbances, Psychosis, Autonomic dysfunction, Falls M: Levodopa, Dopamine Agonist, COMT-inhibitors, MAO-B inhibitors, On-Off Phenomenon (Dose more frequently, Add Apomorphine), Tremor (Anticholinergic), Surgery
28
Rheumatoid Arthritis history - GO!
P: Arthritis of small joints of hands/feet/cervical spine, Increased early morning stiffness improving with movement R: Smoking, Genetics I: RF, ANA, Anti-CCP, X-rays C: Eyes (scleritis, episcleritis), Skin (Raynaud's phenomenon), Neck (C1-2 subluxation), Lungs (ILD, Pleural effusion, Nodules), Heart (Pericarditis, Increased Atherosclerosis), Renal (Amyloidosis), Nervous system (Peripheral neuropathy, Mononeuritis multiplex), Haematological (Anaemia, Neutropaenia, Splenomegaly) M: Physiotherapy, Occupational therapy, Smoking cessation, NSAIDs, DMARDs (Methotrexate, Sulfasalazine, Hydroxychloroquine, Leflunomide), Biological Agents (TNF inhibitors, Anakinra IL-1 Antagonist, Tocilizumab IL-6 inhibitor, Abatacept costimulatory anti-T cell therapy), Surgery
29
Ankylosing Spondylitis history - GO!
P: Back pain > 3 months in early morning, may disturb sleep, Age <45, Heel pain, Uveitis, IBD R: HLA-B27 I: HLA-B27, RF negative, X-Rays C: Sacroiliitis, Uveitis, Plantar fasciitis, Costochondritis, AR, Respiratory failure M: Physiotherapy, NSAIDs, TNF Inhibitors, Secukinumab (IL-17 inhibitor)
30
SLE history - GO!
P: Malar rash, Photosensitivity, Arthritis, Serositis (pleurisy, pericarditis), Seizures, Psychosis, Haematuria R: Medications (Procainamide, Hydralazine, Isoniazid, Methyldopa, Penicillamine, Minocycline, TNF inhibitors) I: ANA, Anti-dsDNA, Anti-Smith, Lupus anticoagulant, Anticardiolipin antibodies C: Musculoskeletal (arthralgia), Dermatological (rash, ulcers), Neuropsychiatric (Delirium, stroke, mononeuritis multiplex), Renal (glomerulonephritis), Haematological (anaemia), Respiratory (pleural effusion, ILD), Heart (pericarditis, myocarditis, premature coronary artery disease) M: Arthralgias (NSAIDs, MTX), Skin (Hydroxychloroquine), CNS / Respiratory / Cardiac / Haemolytic anaemia (Steroids), Lupus Nephritis (Steroids + AZA/MMF).
31
Systemic Vasculitis history - GO!
P: Fatigue, Fever, Myalgia, Arthralgia, Rash (palpable purpura), GPA (Haemoptysis, Dyspnoea, Nasal congestion), GCA (Headache, Visual disturbance, Visual loss, Jaw claudication), EGPA (Asthma, Allergic rhinitis, Cough, Dyspnoea) R: Smoking, Genetics I: Biopsy of affected tissue, ESR, Hb, Renal function, Urinary casts/dysmorphic RBCs, CXR. C: Pulmonary haemorrhage, Renal failure, Blindness (GCA), PAN => Mesenteric ischaemia, MPA => pulmonary renal syndrome M: Treat underlying cause, Steroids, Immunosuppressants
32
Antiphospholipid Antibody Syndrome history - GO!
P: Arterial/Venous Thrombosis, Pregnancy complications (miscarriage, stillbirth, pre-eclampsia, preterm delivery), Stroke, MI, Haemolytic anaemia R: Autoimmune diseases e.g. SLE, Genetics I: Antibodies (Lupus anticoagulant, Beta-2-Glycoprotein, Anti-Cardiolipin) C: Thrombosis, Pregnancy complications, Catastrophic APLS M: Anticoagulation. CAPLS (Plasmapharesis, IVIG, IV Heparin)
33
Systemic Sclerosis history - GO! -------------------------
P: Calcinosis, Raynaud's phenomenon, Esophageal dysmotility, Sclerodactyly, Telangiectasia, ARthropathy, ILD, Pulmonary hypertension, Dilated cardiomyopathy, Scleroderma renal crisis. R: Steroid use, Smoking I: Limited (anticentromere antibody), Diffuse (Anti-Scle-70 antibody), Gastroscopy, PFTs, TTE, HRCT, RHC, 6MWT C: ILD, Pulmonary hypertension, Dilated cardiomyopathy, Scleroderma renal crisis M: Avoid smoking/beta-blocker/cold weather, Raynaud's (CCB, Prazosin, Methyldopa), GORD (PPIs), ILD (Immunosuppressants), Pulmonary hypertension (Endothelin receptor antagonists, Phosphodiesterase inhibitors, Prostanoids), Renal Crisis (ACEi), Severe Diffuse Systemic Sclerosis (Myeloablative Autologous Haematopoietic Stem Cell Transplant)
34
How would you manage falls in the elderly?
- exercise: BALANCE TRAINING - vitamin D: prevents fractures and falls - review meds: psychoactives and benzos - OT home visit - no bifocals - cataract surgery - podiatry/footwear/orthotics - hip protectors
35
Prednisone complications Hx
- thin skin/easy bruising - wt gain, moon face - Diabetes, Hypertension - OP: fractures, BMD, OP treatment - infections
36
Falls Ix
- ECG/telemetry - postural BP - timed up and go text (up, 3m, sit down)
37
What are some obesity 2' causes?
Hypothyroidism Drugs/Meds: prednisone, antidepressants Cushing's disease Hypogonadism
38
What are non pharm mx of obesity?
``` Regular clinic follow up Small achievable goals Enlist family help Food diary, exercise diary Dietician Exercise within limits: swimming, aquarobics Very low calorie diet (Optifast) ```
39
Indications for bariatric surgery?
- BMI 40+ or BMI 35+ and at least one comorbidity related to obesity (DM, OSA, HTN) - obese for >5 yrs - participation in exercise program, motivated - psychological assessment - failed previous non Surg therapy
40
What are some pharmacological Mx for obesity?
- treat underlying depression - orlistat: 1st line, lipase inhibitor, causes steatorrhea - phentermine (an amphetamine): SE- not safe for pulm HTN; uncontrolled HTN; IHD and cerebrovascular disease - if DM, metformin and exenatide, a GLP1RA glucagon like peptide antagonist (incretin mimetic)
41
For obesity, explain Optifast diet and some side effects:
1) Intensive phase: 3 Optifast/day + 2cups low starch vegetables 2) Transition: 2 Optifast & 1 meal -> 1 Optifast & 2 meals -> 3 meals SE: gallstones (prevented by adding teaspoon of olive oil daily), muscle cramps, hair loss, fatigue
42
Obesity, what associated conditions to screen for?
- OA - OSA - NASH - metabolic syndrome: DM, HTN, hyperchol, obesity - cardiovascular - skin - psych: depression, isolation
43
What are some non pharmacological strategies for smoking cessation?
- manage cravings: gum, keep hands occupied - avoid high risk situations: post work drinks, etc - quit line - support groups - exercise
44
What are some PHARMACOLOGICAL strategies for smoking cessation? (And side effects/contraindications)
NRT: - Start with high dose patches, before bed - If still smoking, add PRN gum/lozenge/spray - SE: skin irritation, nausea, nightmares - CI: pregnancy, within 48hrs of ACS Varenicline (Champix) - partial nicotine receptor agonist Buproprion: (Zyban) - A Norad/5HT/Dopa reuptake inhibitor - SE: insomnia, tremor, nausea - CI: seizures
45
What are your Ix for osteoporosis?
- EUC/renal function (risk with OP) - Calcium/Vit D levels - BMD/DEXA (T score
46
What is approach to osteoporosis management?
- confirm dx with BMD, assess CMP/vit D levels - 1st line: Vitamin D replacement, Calcium supplements - Bisphosphonate: dental review, CI in renal failure - Denosumab - Teriparatide for severe OP (PTH analogue) - Decrease falls risk: vision, medications, OT, walking aids, hip protectors, balance/strength training
47
What is your approach to this patient's alcohol abuse?
``` Assess impact of EtOH use: - liver/social - comorbidities: anxiety/depression, susbtance abuse Assess motivation/insight: - advise abstinence or cut down Detox - inpatient or outpatient - thiamine replacement - AWS - benzos for DT/withdrawal Prevent relapse: - Naltrexone, acamprosate - disulfiram Harm reduction: - revoke license - FACS referral ```
48
What are the definitions of NYHA classes?
Class 1: No impairment Class 2: Some impairment with normal activity Class 3: Severe impairment with minimal exertion Class 4: SOB at rest
49
What is approach to depression?
1) 4P's: predisposing, precipitating, perpetuation, protective factors 2) Risk Ax: low/med/high, self/others, intent/plans 3) Management: Non pharm: exercise, support groups, mood diary Pharm: 1st line SSRI, 2nd line: escitalopram, add psych input GP mental health plan
50
What is your approach to this guy's non-compliance?
``` Assess reason: - level of understanding: education - poor motivation: ?depression, social supports - lifestyle - medication factors: pill burden, complexity, cost, access to medications Manage: - apps/reminders - enlist help of carers/family - liaise with GP, pharmacist - Webster pack - positive reinforcement ```
51
What is the ECOG performance status?
0. Fully active 1. Light work ok 2. Self care, but no work; out of bed >50% of day 3. Limited self care; in bed >50% of day 4. Completely disabled 5. Dead
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What are the stages to smoking/addiction cessation?
1. Pre contemplation 2. Contemplation 3. Planning 4. Action 5. Maintenance
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What is your management plan for CCF?
Ix precipitant: non compliance, infection, anaemia, MI Non pharmacological: - education - nutrition/dietician: low Na diet, 1.5L FR - cardiac rehab: walking, light resistance training - weight reduction Pharmacological/Medical Mx: - ACEi, B-blocker, diuretics/frusemide/spiro - CRT: if LBBB/QRS>120, EF
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Multiple myeloma history - GO!
P: Bone pain, fracture, infection, anaemia, bleeding, renal disease (stones, failure, infection), hypercalcaemia, hyperviscosity (esp IgM), spinal cord compression, skin changes, amyloidosis R: Petroleum exposure, nuclear radiation exposure I: Film- rouleaux, raised ESR; Serum/urine Light chains (abnormal Kappa:Lambda ratio); EPG = monoclonal globulin peak=>proceed to immuno fixation electrophoresis (IFE) which identifies as IgG. - Skeletal surveys (not bone scan as not osteoblastic) - MRI to exclude nerve root or cord compression - Calcium/urate level; Renal function M: High dose steroid + thalidomide/ lenolidamide -Cyclophosphamide (damages stem cells, Risk of 2° leukaemia, prevents future SCT) and bortezomib (proteosome inhibitor) are alternatives -Autologous stem cell for relapse in suitable patient -Treat "CRAB" and avoid live vaccines
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Classic diagnostic criteria for Multiple Myeloma
>Dx: 10% plasma cells + end organ damage - Classic disease - ↑serum paraproteins > 30g/L - Light chain disease - low/nil serum paraproteins, predominant urinary light changes (BJ, increased rat kappa/ lamda) ∴ may be missed on standard QUEP - non secretory - very rare, needs BM bx for dx >DDx. - MGUS - Waldenstrom’s macroglobulinaemia - Solitary plasmacytoma - POEMS (peripheral neuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes)
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Staging of Multiple Myeloma
1. Stage I = B2M < 3.5, serum Alb > 35; Median surv 62 months 2. Stage II = neither 1 or 3; Median surv 44 months 3. Stage III = B2M > 5.5; Median surv 29 months >Prognosis: -largely depends on cytogenetic profile. -Average survival 5-6 years post autologous SCT
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Treatment of Multiple Myeloma
1. Bone pain and cord compression = DXT, bisphosphonates (improve pain, QOL, survival) 2. Renal: RRT/ Hydration/ avoid contrast/ allopurinol for urate 3. Anaemia = erythropoeitin may help 4. Stage II - III or rising myeloma protein - high dose steroids + thalid/lenalidomide (reduce TNF-a) OR Bortezomib (proteosome-i) - Autologous SCT (good ECOG and prognostics) 5. Alkylating agents (melphalan, cyclophosphamide) - damage stem cells and prevent harvesting - avoid if may be candidates for stem cell tx. 6. Older patients (ineligible for stem cell) - MTP = melphalan, thalidomide, prednisone - VMP = bortezomib, melphalan, prednisone
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What agents are used in myeloma treatment? | What are the SEs of myeloma treatment?
1) bortezomib (velcade) - Peripheral neuropathy, Thrombocytopaenia 2) Lenalidomide/ Thalidomide - VTE, secondary malignancy 3) Melphalan/ cyclophosphamide - myelosuppression, infertility, secondary malignancy
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Multiple sclerosis What is Uthoff phenomenon? What is Lhermitte sign?
>Uthoff - Worsening of MS symptoms with hot temperatures | >Lhermitte - Electric shock down arms with neck flexion
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What investigations for MS? And how to diagnose?
MRI: lesions separated in time and place LP: oligoclonal bands in CSF Visual evoked potential: slow
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What is the management of MS? | Acute and long term
Acute: pulsed methylprednisolone x3 days Long term: - IFN B (SE: flu like illness) - glatiramer - natalizumab (SE: PML 2' JC virus) - fingolimod (SE: increased infection risk) - MTX/AZA
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What are the different types of MS?
- relapsing remitting: recovery between episodes - secondary progressive - primary progressive - progressive relapsing - CIS: clinically isolated syndrome: optic neuritis
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What investigations for MG?
- tensilon test (improvement with edrophonium- increases ACh, but can cause cholinergic crisis requiring atropine) - anti AchR Ab - anti MUSK Ab - EMG - TFT, RF, ANA - PFT - CT: thymoma
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How would you manage MG?
- pyridostigmine - steroids of severe disease - immunosuppressives: AZA, MMF if steroids no work - rituximab: last resort - Thymectomy
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What are the treatment options for PD?
- dopamine agonists - levodopa/carbidopa - COMT inhibitor - MAO-B inhibitor - amantadine - surgical: DBS
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What are the side effects of dopamine agonists?
- impulsivity | - postural hypotension
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What are the side effects of levodopa/carbidopa?
- nausea | - postural hypotension

Hark and Paul's clinical review (12 decks)

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