Long Case misc

Question 1

How would you manage falls in the elderly?

Answer 1

• 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

Question 2

What are your Dyspnea DDx?

Answer 2

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

Question 3

What Ix for Dyspnea?

Answer 3

• 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

Question 4

Prednisone Hx

Answer 4

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

Question 5

Prednisone complications Hx

Answer 5

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

Question 6

Falls Ix

Answer 6

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

Question 7

What are some obesity 2’ causes?

Answer 7

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

Question 8

What are non pharm mx of obesity?

Answer 8

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)

Question 9

Indications for bariatric surgery?

Answer 9

• 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

Question 10

What are some pharmacological Mx for obesity?

Answer 10

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

Question 11

For obesity, explain Optifast diet and some side effects:

Answer 11

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

Question 12

Obesity, what associated conditions to screen for?

Answer 12

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

Question 13

What are some obesity 2’ causes?

Answer 13

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

Question 14

What are non pharm mx of obesity?

Answer 14

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)

Question 15

Indications for bariatric surgery?

Answer 15

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

Question 16

What is the pharmacological Mx for obesity?

Answer 16

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

Question 17

For obesity, explain Optifast diet and some side effects:

Answer 17

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

Question 18

Obesity, what associated conditions to screen for?

Answer 18

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

Question 19

What is your general approach to smoking cessation?

Answer 19

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

Question 20

What are some non pharmacological strategies for smoking cessation?

Answer 20

• manage cravings: gum, keep hands occupied
• avoid high risk situations: post work drinks, etc
• quit line
• support groups
• exercise

Question 21

What are some PHARMACOLOGICAL strategies for smoking cessation? (And side effects/contraindications)

Answer 21

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

Question 22

What are your Ix for osteoporosis?

Answer 22

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

Question 23

What are the features of a venous ulcer

Answer 23

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

Question 24

What are the features of an arterial ulcer

Answer 24

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

Question 25

What are the features of a neuropathic ulcer

Answer 25

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

Question 26

What are the differentials for a lower limb ulcer?

Answer 26

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

Question 27

What is your approach to this patient's alcohol abuse?

Answer 27

``` 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 ```

Question 28

What are the definitions of NYHA classes?

Answer 28

Class 1: No impairment Class 2: Some impairment with normal activity Class 3: Severe impairment with minimal exertion Class 4: SOB at rest

Question 29

What is your management plan for CCF?

Answer 29

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

Question 30

How would you investigate HTN?

Answer 30

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

Question 31

What are targets for BP control?

Answer 31

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

Question 32

How would you manage BP?

Answer 32

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

Question 33

What are the targets for cholesterol?

Answer 33

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

Question 34

How would you manage hypercholesterolaemia?

Answer 34

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

Question 35

What is approach to depression?

Answer 35

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

Question 36

What is your approach to this guy's non-compliance?

Answer 36

``` 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 ```

Question 37

What is approach to osteoporosis management?

Answer 37

- 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

Question 38

What is the ECOG performance status?

Answer 38

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

Question 39

What are the stages to smoking/addiction cessation?

Answer 39

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