spiels

Question 1

what is the HAS-BLED score?

Answer 1

predicts major bleeding (Hb drop > 20, need for transfusion, bleed requiring hospitalisation, ICH) within one year
- hypertension > 160
- abnormal LFT's (bili > 2xULN), renal fn (creat > 200)
- stroke
- bleeding history or anaemia
- labile INR (<60% in therapeutic range)
- elderly > 65yo
- drugs - EtOH or NSAIDs
>4 = high risk

Question 2

What is the Epworth sleepiness scale?

Answer 2

chance of sleeping during activities rated 0-3
- sitting and reading
- sitting and chatting
- sitting after lunch
- watching TV
- inactive in a public place
- as a passenger in a car
- lying down to rest
- at the traffic lights
>16 = needs referral

Question 3

What is the CHADS2-Vasc score?

Answer 3

risk of stroke with AF
C - CHF
H - HTN > 140/90
A - >75yo = 2
D - diabetes
S - stroke/TIA = 2
V - vascular disease (MI, PVD, plaque)
A - age 65-74
Sc - female sex
>2 = recommend anticoagulation

Question 4

What would you consider if you were to anticoagulate this patient?

Answer 4

contextualise based on comorbidities
?aim of anticoagulation
- AF - prevent stroke - CHADS
- CTEPH - mortality benefit
- VTE - prevent complications
risks - use HAS-BLED score
- ask for FBC, renal and liver function tests
- ask for history of INR's if on warfarin
falls is NOT an important risk factor

Question 5

How would you prevent further falls in this patient?

Answer 5

precipitants - foot-ware, home, pathologies
- cardiac arryhthmias
- neuropathy or weakness
- frailty/cognitive impairment
- medications - psychotropics, polypharm
investigations that would help:
- basic bloods - anaemia, vitB12, vitD
- sit-to-stand time
- MMSE/MOCA
- ECG, Holter, NCS
involve OT, PT, pharmacist, dietitian
aim to prevent #, injuries, loss of confidence
follow up in falls clinic/MDT etc.

Question 6

How would you assess this patient’s operative risk?

Answer 6

revised cardiac risk index: one point for each
- type of surgery - Intraperitoneal; intrathoracic; suprainguinal vascular
- IHD - MI, +ve stress test, Q-waves
- HF - S3, rales, CXR with oedema
- TIA/stroke
- pre-operative insulin
- creat > 200
chance of MACE:
1 pt - 1%, 2 - 7%, >3 - >11%

Question 7

Are there any interventions to help optimise this patient for surgery?

Answer 7

assess risk using a calculator (RCRI)
consider non-invasive functional test
- MIBI, stress ECHO, CTCA
- no role for routine angiogram
aspirin - reduces VTE after hip surgery
- continue for cardiac surgery
statin - continue if clinical indication
- consider starting if vascular surgery
beta blocker - not for all routinely
- if IHD, don't stop unless low bp or HR
- if RCRI > 3, consider commencing 1 week before surgery

Question 8

How would you assess this patient’s nutritional status?

Answer 8

objective parameters:
- anthropometry, serum proteins, micronutrient levels
subjective global assessment:
- protein/calorie intake and weight loss
- functional impairment
- clinical signs - muscle wasting, oedema, signs of micronutrient deficiency

Question 9

How would you manage this patient’s non-compliance [lack of adherence]?

Answer 9

explore reasons for non-adherence:

• belief in lack of efficacy - educate, involve family
• complicated regimens - involve pharmacist and reduce polypharmacy
• unable to afford medication - explore cheaper options or access schemes
• intolerant of side effects - alternative Rx
• can’t use medication - poor eyesight or dexterity with puffers or insulin
• cognitive impairment - webster pack or medication aids