Yr4 GenMed - Tutorials Flashcards

Question

Outline the treatment for Functional Dyspepsia (8).

Answer 1

**Alarm symptoms in a patient with Dyspepsia** 1. Unintended weight loss 2. Persistent vomiting 3. Progressive dysphagia 4. Odynophagia 5. Anaemia 6. Haematemesis/melaena 7. Palpable abdominal mass or lymphadenopathy 8. Family history of upper gastrointestinal cancer 9. Previous gastric surgery 10. Jaundice 11. Age over 45-50 yrs 12. Use of aspirin/NSAIDs

Answer 2

= Peptic Ulcer

Answer 3

**Presentations of peptic ulcers** 1. Dyspepsia - DU pain typically 2-3 hours after a meal and relived by food or antacid. Pain often wakes patient late at night (acid secretion without food buffer). GU pain tends to occur sooner after a meal and less likely to awaken at night. 2. Anorexia and weight loss common - Many ulcers are asymptomatic and symptoms are not specific or sensitive 3. Iron deficiency 4. Vomiting 5. Anorexia 6. GI bleeding 7. Perforation

Answer 4

1. Systolic BP < 100mm supine - Can be 40% volume loss 2. Postural drop > 10mm Hg - ?15% blood volume loss 3. Pulse > 100 per minute - Resting tachycardia with <15% volume loss 4. Haemoglobin<80g/L 5. Syncope (collapse) 6. Variceal haemorrhage 7. Comorbidity– age>60yrs, organ dysfunction (heart, kidney, respiratory etc), anticoagulation 8. Rebleed in hospital

Answer 5

**Evaluation of peptic ulcers** - Usually diagnosed by endoscopy - For gastric ulcers, usually do biopsies at time to exclude cancer - Usually also rescope in 10 weeks or so to confirm healing - May get HP serology as well if not biopsied at time of scope

Answer 6

**Proton pump inhibitors for PUD** - On the whole very well tolerated - Best taken on empty stomach before a meal - Once daily dose for peptic ulcers. Twice daily for some indications like refractory reflux - Rebound acid hypersecretion can occur on cessation - Long term concerns: increased infections (C.dif [OR 1.7], pneumonia [OR 1.27]), malabsorption (osteopaenia, magnesium, iron, B12), medication interactions (clopidogrel) - More recently ?dementia link, chronic renal disease, cardiac risk

Answer 7

**Other acid-peptic medications** 1. H2 antagonists: ranitidine, nizatidine 2. Sucralfate- coating agent in stomach. Occasionally used for bile-gastritis 3. Misoprostol: prostaglandin E analog. Shown to reduce risk of NSAID induced ulcers. Developing role for small intestinal NSAID injury.

Answer 8

**Helicobacter pylori** - Gram negative spiral flagellated bacterium - Socioeconomic level seems to be the major determinant of risk of infection - In Australia, 25-30% of population infected, prevalence increases with age - Most infections probably acquired in early childhood

Answer 9

**Testing for HP** 1. Serology (good if you have never been treated for HP). No preparation needed 2. Stool antigen test 3. Breath test which relies on HP urease activity - Need to avoid antibiotics for 4 weeks and PPI for 1-2 weeks 4. Endoscopic biopsy for histology or rapid urease test or culture - Need to avoid antibiotics for 4 weeks and PPI for 1-2 weeks

Answer 10

**Aspirin and NSAIDs in PUD** - These can be absorbed across gastric mucosa but the main problem seems to be systemic (post-absorption) inhibition of GI mucosal cyclo-oxygenase (COX) - Enteric coated agents or rectal delivery still produces risk - Endoscopic evidence of ulceration occurs in 15-30% of chronic users - In a low risk subject, 0.5% risk per year of serious complicated ulcer - 50–60% of NSAID-associated peptic ulcers, presenting for the first time as a complication, have been silent previously. - Potent agents can induce damage after 7 days - Reasonable to test for and eradicate HP in NSAID/aspirin naïve patients - Eradication of HP not adequate alone in setting of complicated ulcer - ?role of misoprostol

Answer 11

**Reasons for suboptimal glycaemic control in Existing Diabetic Patients** 1. Concurrent illnesses - Infection (pneumonia, diabetic feet), myocardial infarction 2. Treatment - Non-adherence & Suboptimal treatment 3. Poor understanding of treatment goals 4. Loss to follow-up 5. Social stressors

Answer 12

In healthy humans, the incretin glucagon-like peptide 1 (GLP-1) is secreted after eating and lowers glucose concentrations by augmenting insulin secretion and suppressing glucagon release. Additional effects of GLP-1 include retardation of gastric emptying, suppression of appetite and, potentially, inhibition of β-cell apoptosis.

Answer 13

**SGLT2 Inhibitors Cause:** 1 - **Glucosuria** → lower blood glucose levels and weight loss. - β-cell: ↓ insulin, ↑ glucagon → ↑ Lipolysis - ↓ Steatosis (NAFLD) 2 - **Natriuriesis** → lower total body water and decreased heart failure = ↓ blood pressure 3 - **Tubuloglomerular feedback activation** → ↓ fibrosis and CKD progression

Answer 14

**Starting basal-bolus regime - Safe doses:** 1. Optisulin 6 - 10 units nocte – use lower dose (6-7 units) if elderly, frail, renal or hepatic impairment, low-normal BMI. Can increase by 2-3 units every 1-2 days in hospital (2-3 days in community) 2. Novorapid 3 – 4 units with meals **Mixed insulins - safe doses** 1. Novomix-30: 6 to 10 units once or twice daily with meals, depending on BGLs, BMI, age, renal function, frailty and oral intake 2. Ryzodeg: 6 to 10 units once or twice daily with meals, depending on BGLs, BMI, age, renal function, frailty and oral intake - Timing of Ryzodeg administration can be changed (eg if once daily, it can be taken with lunch one day and with dinner the next day, as long as the meal it is taken with is the main meal for the day)

Answer 15

**T1DM patients** - If they are cognitively capable (ie no altered GCS due to sepsis, uraemia, stroke, head trauma or sedation, and no psychiatric concerns), it is often safer to allow T1DM patients to have some autonomy over their inpatient diabetes management - Ask about their insulin doses and chart a range. - Eg Novorapid 0 – 6 units tds with meals instead of a fixed dose 4 units tds

Answer 16

**Perioperative management of diabetes medications** 1 - If patient is on a morning operating list and fasting from midnight - Reduce evening long-acting insulin to 70% of the dose. - Patient not to have any of their morning diabetes medications. - Consider ward-based insulin/dextrose infusion (not DKA one) with specific BGL parameters on when to be starting the infusions 2 - If patient is on an afternoon operating list and allowed to have a light early breakfast - Can have morning diabetes medications

Answer 17

- Add insulin at same time as steroid – ideally both should be in the morning. - Might need to cease gliclazide temporarily due to risk of hypoglycaemia.

Answer 18

**Precipitating Causes of DKA** 1. New diagnosis of DM 2. Infection 3. Poor adherence to treatment 4. Other 5. Unknown **Commence DKA protocol – 3 factors to consider** 1. Fluid replacement 2. Insulin 3. Potassium **Main concerns:** Rapid correction of hyperglycaemia can lead to: 1. Hypoglycaemia 2. Cerebral oedema 3. Hypokalaemia 4. Gastroparesis 5. Macular oedema

Answer 19

**SGLT2 inhibitors and DKA epidemiology** - Rare adverse reaction: Up to 1 in 1,000 patients (0.2 to 0.8 cases per 1,000 patient years in T2DM) - Could be life-threatening - Always consider it if non-specific symptoms: Nausea, vomiting, anorexia, abdominal pain, excessive thirst, dyspnoea, confusion, unusual fatigue or sleepiness

Answer 20

**Safe Ketone Levels** - <0.6 mmol/L is a normal range - 0.7 – 2.0 mmol/L – consider prolonged fasting (starvation ketoacidosis) or insulin bolus requirement (usually 2-3 units, depending on BSLs and oral intake) - If hyperglycaemic >15 mmol/L with these ketones, suggest venous blood gas to exclude diabetic ketoacidosis - >2.0 mmol/L and hyperglycaemia– high risk of diabetic ketoacidosis. Need urgent VBG to assess for acidosis

Answer 21

What are you looking for on CXR in a patient with chest pain? 1. Respiratory causes of chest pain 2. Cardiomegaly/ Heart failure 3. Widened mediastinum = aortic dissection

Answer 22

Measure troponin at presentation then 2 hours later. Trops peak at 18 hours from onset of chest pain.

Answer 23

**TIMI** - TIMI Risk Score for UA/NSTEMI estimates mortality for patients with unstable angina and non-ST elevation MI. - Can be used to help risk stratify patients with presumed ischemic chest pain. However, it was originally derived in patients with confirmed unstable angina or non-ST elevation myocardial infarction. - UA/NSTEMI can sometimes be missed. Traditionally, the TIMI Risk Score for UA/NSTEMI can correlate the risk of adverse outcome in chest pain patients.

Answer 24

**Investigations to consider for possible angina** 1. ECG - A normal ECG doesn't rule out ACS! 2. Echo +/- Stress (Exercise or Dobutamine) 3. Myocardial perfusion scan 4. CTCA

Answer 25

Intervene only with symptomatic severe aortic stenosis.

Answer 26

Role of statins in delaying the progression of aortic stenosis = nil - this is a surgical problem - Would still prescribe for other prevention

Answer 27

**Radial Angiography** - 5F diagnostic - 6F Intervention - Dedicated radial catheters - Radial cocktail: 1. Heparin 3000units 2. GTN 200mcg 3. Light sedation - midazolam and fentanyl **Angiogram** - Shows severe stenosis at the bifurcation of the LAD - Management options – Stent (doesn’t require GA) or bypass graft (if she’s having a surgical/mechanical valve replacement anyway but if high surgical risk then valves fixed with TAVI = tissue valve, not a long lasting as mechanical valves).

Answer 28

- Narrow-complex tachycardia - Irregularly, Irregularly = likely AF - V4, V5, V6 (lateral lead) = ST Depression – typically rate related ischemia but could be true ischemia (ask if any angina in the past few weeks)

Answer 29

If >2 on CHADS-VASC then anticoagulate unless your 2 points come from female gender and age >65yrs

Answer 30

**Rate Control** 1. Digoxin 2. Beta blocker (Metoprolol) 3. Ca Channel Blocker (Verapamil) **Rhythm Control** 1. Amiodarone 2. Flecainide 3. Sotalol 4. Dronedarone

Answer 31

**Sotalol** is a methane sulfonanilide beta adrenergic antagonist used to treat life-threatening ventricular arrhythmias and to maintain sinus rhythm in atrial fibrillation or flutter. - **MOA**: Sotalol is a competitive inhibitor of the rapid potassium channel. This inhibition lengthens the duration of action potentials and the refractory period in the atria and ventricles.

Answer 32

**Amiodarone** is a class III antiarrhythmic indicated for the treatment of recurrent hemodynamically unstable ventricular tachycardia and recurrent ventricular fibrillation. - Amiodarone is a benzofuran derivative, anti-arrhythmic drug used commonly in a variety of settings.4 Most known for its approved indication in life-threatening ventricular arrhythmias, it is also used off-label in the outpatient and inpatient setting for atrial fibrillation.

Answer 33

**Flecainide** is a class Ic antiarrhythmic agent used to manage atrial fibrillation and paroxysmal supraventricular tachycardias (PSVT). The main contraindications for treatment with flecainide are ischemic heart disease, hypertension with left ventricular hypertrophy (LVH), congestive heart failure, hypertrophic cardiomyopathy, degree 2 and 3 atrioventricular blocks, complete bundle branch block and significant liver and kidney disease.

Answer 34

**Digoxin** is a cardiac glycoside used in the treatment of mild to moderate heart failure and for ventricular response rate control in chronic atrial fibrillation. - Digoxin is indicated in the following conditions: 1) For the treatment of mild to moderate heart failure in adult patients 2) To increase myocardial contraction in children diagnosed with heart failure 3) To maintain control ventricular rate in adult patients diagnosed with chronic atrial fibrillation.

Answer 35

PVI = Pulmonary Vein Isolation +/- atrial substrate modification

Answer 36

**Oral Anticoagulation Options for AF** Warfarin (Coumadin or Marevan) VS. NOAC (Novel Oral Anticoag) - Factor Xa inhibitors 1. Apixaban (Eliquis) 2. Rivaroxaban (Xarelto) - Direct Thrombin Inhibitors 1. Dabigatran (Pradaxa) Others under development - Is there a preferred anticoagulant for AF? = Yes and No - Warfarin out of favour whilst NOACs compare favourable compared to Warfarin. - Which NOAC should I use? = There are no head to head studies comparing NOACs

Answer 37

**Vitamin K Antagonists** - Warfarin (Coumadin or Marevan) is most commonly prescribed - Derived from Coumarin - Inhibits Vit K dependent synthesis of clotting factors = 2, 7, 9, 10, Protein C, Protein S, Protein Z - 48-72 hours for INR to be therapeutic - Pro-coagulant effect - Protein C

Answer 38

**Reversal Agents** **Warfarin** - Vit K (0.5-5mg) time of onset = 24/24 - Blood products = Prothrombin complex concentrate & FFP **NOAC** - Dabigatran (Idarucizumab) - Rivaroxaban/Apixaban (developed but not available)

Answer 39

**What would you check for clinically if you suspect a NOF?** Leg is shortened & externally rotated **What pain relief would you consider?** - Tapentadol = oral only so not fast enough action PLUS patient may need to go to theatre later so need to fast them so not a good option - IV morphine OR sublingual fentanyl - Regional block = lower chances of systemic side effects – especially delirium in the elderly o Eg. Femoral nerve block (medial to lateral: Nerve, Artery, Vein, empty space, lymph nodes)

Answer 40

**Differential Diagnoses of NOF** - Alternative fractures, such as of the pelvis (especially pubic ramus fractures), acetabulum, femoral head and femoral diaphysis, all need to be considered. - Pathological fractures should be considered if there is not a significant history of trauma.

Answer 41

- The blood supply to the neck of the femur is retrograde, passing from distal to proximal along the femoral neck to the femoral head. This is predominantly through the medial circumflex femoral artery, which lies directly on the intra-capsular femoral neck. - Consequently, displaced intra-capsular fractures disrupt the blood supply to the femoral head and, therefore, the femoral head will undergo avascular necrosis (even if the hip is fixed). Patients with a displaced intra-capsular fracture therefore require joint replacement (arthroplasty), rather than fixation. - There is supply in the early days of life from the ligamentum arteriosum, which lies within the ligamentum teres, however this dramatically reduces in size in later life, and is of negligible importance in adults

Answer 42

Neck of femur (NOF) fractures can occur anywhere from the subcapital region of the femoral head to 5cm distal to the lesser trochanter.

Answer 43

- **Grade 1** = Dynamic hip screw & plate (know the blood supply is intact) - **Grade 2** = Dynamic hip screw & plate (1/5 failure rate resulting in necrosis, presents as increased groin pain approx. 4-6 weeks post-surgery) - **Intertrochanteric fracture** = Dynamic hip & screw - **Grades 3 + 4** = Hemiarthroplasty (know the blood supply is not intact) - **Atypical Subtrochanteric** = proximal nail - **Hemiarthroplasty** = partial joint replacement because they know the head will necrose due to the lack of blood. (Grades 3 + 4)

Answer 44

= Intertrochanteric fracture - Also take a lateral hip x-ray! Mx = Dynamic hip & screw for an Intertrochanteric fracture

Answer 45

Encephalopathic – potentially reversible Impaired cognition to make decisions Not medically stable

Answer 46

**State Administrative Tribunal (SAT)** * Independent body that reviews a wide range of government decisions and determines disputes. * Wide Jurisdiction extends to guardianship and administration, equal opportunity, vocational regulation, resources, and development (including town planning, and commercial and civil disputes).

Answer 47

**Decision-making Disability** 1. Neurodegenerative Disease - eg. Dementia 2. Delirium 3. Neurocognitive developmental conditions 4. TBI leading to Intellectual impairment/Acquired Brain injury 5. Stroke 6. Encephalopathies – Infective, Metabolic, Electrolyte imbalances 7. Substance abuse (acute intoxication or chronic use) 8. Mental illness (acute vs. chronic)

Answer 48

**Guardian** – healthcare, lifestyle, living situation (everything but finances) - Makes personal, lifestyle, and treatment decisions for a represented person with a decision-making disability. - A guardian cannot: Vote, Make or change a will, Consent to a marriage **Administrator** – finances but can’t change will Least Restrictive Pathway - Appointment of a guardian and/or administrator involves removing a person's fundamental decision-making rights. Therefore, it is a LAST RESORT course of action undertaken by the SAT. - Only considered after less restrictive measures of managing the person's best interests have been found to be insufficient.

Answer 49

What is the difference between plenary and limited orders? - **Plenary**: Applies to all areas of the person's life. - **Limited**: Decision-making authority of the guardianship order limited to specific areas only (eg. medical, accommodation)

Answer 50

**When might a healthcare professional be asked to asked to assess capacity?** In response to certain triggers: 1. To facilitate future planning (EPA, EPG, AHD) 2. Routine clinical care assessment (capacity to drive, capacity to consent to medical treatment) 3. Concerns from others re a person's decision-making ability (by family, carer, service provider, GP, other doctors, social worker, lawyer) - assessment requested.

Answer 51

**The six-step capacity assessment process** 1. Identify the reason for assessing capacity (trigger). 2. Engage the person being assessed in the process. 3. Gather information to describe the context, choices and their consequences. 4. Educate the person about the context, choices and their consequences. 5. Assess capacity. 6. Take action based on results of the assessment. Whatever the outcome of the assessment, keep a careful record of the whole process in the patient's records.

Answer 52

**Hierarchy of Treatment Decision-makers** * 'Treatment' refers to any medical, surgical or dental treatment or other health care, including a life-sustaining measure or palliative care. * A treatment decision is a decision to consent or refuse consent to commencement or continuation of treatment. * Treatment is regarded as urgent if needed to save a person's life or prevent the person from suffering significant pain or distress. * Where a person requires urgent treatment and not practicable to determine whether an Advance Health Directive has been made or to obtain a treatment decision from anybody in the hierarchy, the health professional may provide the necessary treatment.

Answer 53

**Which score/scale to use?** - Approximately 34 different LVO prediction instruments - Most prediction instruments were derived from elements of the NIHSS - Significant heterogeneity - Cincinnati Prehospital Stroke Screen, Los Angeles Motor Scale (LAMS), Los Angeles Prehospital Stroke Screen, Rapid Arterial Occlusion Evaluation (RACE) - RACE is currently used in Perth for stroke bypass - Australian studies for NIHSS-8 and ACT-FAST designed for use by ambulance.

Answer 54

**Strong Recommendation** 1. All stroke patients should be admitted to hospital and be treated in a stroke unit with an interdisciplinary team. 2. All acute stroke services should implement standardised protocols to manage fever, glucose and swallowing difficulties in stroke patients. **Practice Points** 1. All stroke patients should be admitted directly to a stroke unit (preferably within three hours of stroke onset). 2. For patients with suspected stroke presenting to non-stroke unit hospitals, transfer protocols should be developed and used to guide urgent transfers to the nearest stroke unit hospital. 3. Where transfer is not feasible, smaller isolated hospitals should manage stroke services in a manner that adheres as closely as possible to the criteria for stroke unit care. 4. Where possible, stroke patients should receive care in geographically discrete units.

Answer 55

**Consensus-based recommendation** 1. In stroke patients with brain oedema and raised intracranial pressure, osmotherapy and hyperventilation can be trialled while a neurosurgical consultation is undertaken. 2. For selected patients with large cerebellar infarction threatening brainstem and 4th ventricular compression, decompressive surgery should be offered.

Answer 56

**Neuroprotection** 1. For stroke patients, putative neuroprotective agents, including hypothermic cooling, are not recommended outside the context of research. 2. Patients with acute ischaemic stroke who were receiving statins prior to admission can continue statin treatment. **Glycaemic therapy** 1. All stroke patients should have their blood glucose level monitored for the first 72 hours following admission, and appropriate glycaemic therapy instituted to treat hyperglycaemia (glucose levels greater than 10 mmol/L), regardless of their diabetic status. 2. For stroke patients, an intensive approach to the maintenance of tight glycaemic control (between 4.0-7.5 mmol/L) is not recommended.

Answer 57

**Patent Foramen Ovale Management** 1. Patients with ischaemic stroke or TIA and PFO should receive optimal medical therapy including antiplatelet therapy or anticoagulation if indicated. 2. In patients with ischaemic stroke aged <60years in whom a patent foramen ovale is considered the likely cause of stroke after thorough exclusion of other aetiologies, percutaneous closure of the PFO is recommended. **Anticoagulation therapy** 1. For patients with ischaemic stroke or TIA, with atrial fibrillation (both paroxysmal and permanent), oral anticoagulation is recommended for long-term secondary prevention. 2. Direct oral anticoagulants (DOACs) should be initiated in preference to warfarin for patients with non-valvular atrial fibrillation and adequate renal function. 3. For patients with valvular atrial fibrillation or inadequate renal function, warfarin (target INR 2.5, range 2.0-3.0) should be used. Patients with mechanical heart valves or other indications for anticoagulation should be prescribed warfarin. 4. For patients with ischaemic stroke, the decision to begin anticoagulant therapy can be delayed for up to two weeks but should be made prior to discharge.