- bloods: FBC, trop, BNP - ABG - imaging: CXR, (high res)CT, CTPA, VQ - spirometry and formal PFT - PEF - infective: sputum culture, viral swabs, urine Ag - bronchoscopy - biopsy

- why on pred - duration - highest, lowest, current dose - complications - vaccinations

- ECG/telemetry - postural BP - timed up and go text (up, 3m, sit down)

Long Case misc Flashcards by D W

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

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What are your Dyspnea DDx?

pulm edema/CCF
infective
obstructive lung disease: COPD/asthma
fibrosis: IPF, interstitial lung disease
pulm HTN
haematologic: anemia

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What Ix for Dyspnea?

bloods: FBC, trop, BNP
ABG
imaging: CXR, (high res)CT, CTPA, VQ
spirometry and formal PFT
PEF
infective: sputum culture, viral swabs, urine Ag
bronchoscopy
biopsy

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Prednisone Hx

why on pred
duration
highest, lowest, current dose
complications
vaccinations

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Prednisone complications Hx

thin skin/easy bruising
wt gain, moon face
DM
OP: fractures, BMD, OP treatment
infections

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Falls Ix

ECG/telemetry
postural BP
timed up and go text (up, 3m, sit down)

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What are some obesity 2’ causes?

Hypothyroidism
Drugs/Meds: prednisone, antidepressants
Cushing’s disease
Hypogonadism

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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)

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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

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What are some pharmacological Mx for obesity?

treat underlying depression
orlistat: 1st line
if DM, metformin and exanitide

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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, muscle cramps, hair loss, fatigue

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Obesity, what associated conditions to screen for?

OA
OSA
NASH
metabolic syndrome: DM, HTN, hyperchol, obesity
cardiovascular
skin
psych: depression, isolation

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What are some obesity 2’ causes?

Hypothyroidism
Drugs/Meds: prednisone, antidepressants
Cushing’s disease
Hypogonadism

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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)

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Indications for bariatric surgery?

BMI 35+
at least one comorbidity related to obesity (DM, OSA, HTN)
obese for >5 yrs
participation in exercise program
psychological assessment

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What is the pharmacological Mx for obesity?

treat underlying depression
orlistat: 1st line, inhibit fat absorption
phentermine: SE pulm HTN
if DM, metformin and exanitide

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, muscle cramps, hair loss, fatigue

Obesity, what associated conditions to screen for?

OA
OSA
NASH
metabolic syndrome: DM, HTN, hyperchol, obesity
cardiovascular
skin
psych: depression, isolation

What is your general approach to smoking cessation?

acknowledge difficulty
set realistic goals
educate
enlist family help
regular follow up
non pharm and pharm strategies

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

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

What are your Ix for osteoporosis?

EUC/renal function (risk with OP)
Calcium/Vit D levels
BMD/DEXA (T score

What are the features of a venous ulcer

only mild to moderate pain
shallow with irregular border
gaiter distribution
most common cause of LL ulcers

What are the features of an arterial ulcer

very painful
distally on toes or on pressure areas, such as heel, malleoli and shin
punched out lesion/well demarcated edges

What are the features of a neuropathic ulcer

- not painful | - over pressure points on foot or heel

What are the differentials for a lower limb ulcer?

- venous ulcer - arterial ulcer - neuropathic ulcer - skin malignancy: SCC, BCC (Rodent Ulcer) - vasculitis - infection

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 - DOCS referral ```

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

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

How would you investigate HTN?

- ECG: LVH, IHD - UA: proteinuria, ACR - CXR - TTE 2' causes: renal U/S, 24hr cortisol, metanephrines, sleep study

What are targets for BP control?

Without CVD: BP less than 140/90 If CVD, DM: less than 130/80

How would you manage BP?

Non Pharm: low Na diet, lower etoh, exercise, stop smoking, education Pharm: - ACEi, ARB, CCB, or thiazide

What are the targets for cholesterol?

Total cholesterol less than 4 LDL less than 2 TG less than 2 HDL greater than 1

How would you manage hypercholesterolaemia?

- diet - statins: rosuvastatin is best for avoiding interactions - ezetemibe if statin CI - monitor and prevent IHD/PVD/MI/Stroke

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

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 ```

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

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

What are the stages to smoking/addiction cessation?

1. Pre contemplation 2. Contemplation 3. Planning 4. Action 5. Maintenance