Extra

Cardiology

Ischaemic Heart Disease history

1. D – Diagnosis:
   • When was it diagnosed?
2. R – Risk:
   • HTN, DM, FHx, Smoker, Obese
3. P – Presentation:
   • How did you present it?
   • Did you have a hospital admission?
4. P – Progression:
   • Do you get chest pain now with exertion or rest?
   • Exercise tolerance?
   • PND, Orthopnea, ankle oedema
5. I – Investigations:
   • What investigations were conducted, and what were the results initially?
   • ECG, Echo, Exercise stress test, CTCA
6. M – Management:
   • Did you get PCI or CABG?
   • What medications? – Aspirin +/- Clopidogrel, ACEi or ARB, Beta blocker, Statin, Nitrates
   • Management of risk factors; LDL < 1.8
   • Cardiac Rehab?
7. M – Monitoring
   • Who monitors? – Do you see cardiologist
   • Progress tests/echo
   • Change in meds?
8. C – Complications:
   • Complications such as arrhythmias, cardiac failure, further angina and embolic events.
9. O – Outcome:
   • What is the expected outcome or prognosis for this patient?
   • Impact in patient

Examination

Cardiovascular exam and make sure:

– Blood pressure

– Look for signs of valvular heart disease, cardiac failure, rhythm disturbances (AF) and murmurs suggesting mitral regurgitation or a VSD caused by an infarct. 

– Examine the arms for the very large scar that results from radial artery harvesting.

– Examine the legs for saphenous-vein-harvesting wounds. Infection and breakdown of these wounds are more common than for the sternal wound. 

 

Investigation

These are aimed at assessment of the infarct size, complications and presence of further ischaemia:

1. left ventricular function – echocardiogram, left ventriculogram 
2. complications – echocardiogram for valvular regurgitation, left ventricular throm- bus, infarct-related VSD
3. further ischaemia – exercise test, sestamibi stress test, cardiac catheterisation
4. viability – MRI scan, sestamibi scan. 

 

Management

• Long-term treatment
  • Early revascularization 
  • Prognosis is improved with aspirin, beta-blockers and, for large infarcts (ejection fraction <40%), ACE inhibitors and beta-blockers (e.g. carvedilol, bisoprolol, nebivolol and extended-release metoprolol).
  • Patients with three-vessel disease and significant left ventricular damage or with left main coronary artery stenosis benefit prognostically from coronary artery bypass surgery even if their symptoms have settled on medical treatment. 
  • Epleronone, an aldosterone antagonist, is indicated for patients with cardiac failure following an infarct.
• Secondary prevention
  • Managing cardiac risk factors
  • Dietary advice & exercise for weight loss, statins for dyslipidemia, BP control, smoking cessation. 
  • Cardiac rehab

 

Revascularisation history

• D – Diagnosis

1. 1. 1. When was this done?

• R – Risk

1. 1. 1. Risk factors before and after procedure?

• P – Presentation:

1. 1. 1. Have you ever had an infarct?
      2. Any left ventricular damage?

• P – Progression:

1. 1. 1. Any symptoms such as angina? SOB?

• I – Investigations:

• M – Management:

1. 1. 1. What procedure was performed and the symptoms have completely resolved?
         1. PCI vs CABG?
         2. PCI – How many stents? BMS or DES?
         3. ABG – how many grafts? Which artery is used?
      2. DAPT?

• M – Monitoring

1. 1. 1. Do you see a cardiologist?

• C – Complications

1. 1. 1. Arrhythmia?
      2. Heart failure?

• O – Outcome

Infective Endocarditis history

1. 1. D – Diagnosis:
      • When was it diagnosed? 
   2. R – Risk:

• IVDU, recent dental, endoscopic or operative procedures, hx of rheumatic fever

1. 1. • Immunosuppression, transplant or steroid use
   2. P – Presentation:
      • How did you present? Fever, Malaise, Anaemia?

• Embolic phenomena? Brain, viscera, kidney, haemuturia, loin pain

1. P – Progression:
   • Do you get chest pain now with exertion or rest?
2. I – Investigations:
   • Number of blood cultures
   • TTE/TOE
3. M – Management:
   • Any antibiotic prophylaxis?
   • Antibiotics used?
   • Who monitors? 
4. C – Complications:
   • Any complications?
5. O – Outcome:
   • What is the expected outcome or prognosis for this patient?
   • Impact in patient

Examination

1. Hands – clubbing, splinter haemorrhases, osler nodes, janeway lesions
2. Eyes – Roth spots
3. heart – valvular disease – mitral regurg/stenosis, aortic stenosis/regurg
4. Abdomen – Splenomegaly
5. Neuro signs of embolic disease
6. Joints – rheumatic fever pattern

Investigation

1. Blood cultures
2. FBE, ESR
3. Renal function
4. CSR
5. ECF
6. Echo

Management

1. IV Abx
2. Valve replacement
3. Antibiotic prophylaxis

Congestive Cardiac Failure history

1. 1. D – Diagnosis:
      1. When was it diagnosed?
   2. R – Risk:
      1. Precipitory factors – Arrhythmias, MI, discontinuing meds, not adhering to FR, Anaemia, Thyrotoxicosis, infection, surgery, PE 
      2. HTN, IHD, RHD, valve disease, congenital heart disease, previous cardiac surgery, cardiac transplantation
      3. HTN, Hyperlipidemia, DM, smoking, FHx, Obesity, OCP
   3. P – Presentation:
      1. Sx – Dsypnoea, Orthopnoea, PND, Oedema, Ascites, Anorexia, Angina
   4. P – Progression:
      1. Exercise tolerance? 
      2. NYHA
         1. I No limitation of physical activity. Ordinary physical activity does not cause angina / dyspnoea.
         2. II Angina/dyspnoea on moderate activity.
         3. III Angina/dyspnoea on mild activity.
         4. IV Angina/dyspnoea at rest.
   5. I – Investigations:
      1. Echo, Ejection Fraction?
   6. M – Management:
      1. What medications currently on? ACEi/ARB, ARNI, beta blocker, Furosemide, Spironolactone, SGLT2i

• M – Monitoring

1. 1. C – Complications
      1. Any complications? Arrhythmias?

• Outcome

1. 1. Find out how the disease affects the patient’s life and ability to cope at home (e.g. climbing stairs, sexual difficulties, etc

Examination

1. Perform a detailed cardiovascular system examination.
2. Look particularly for signs of cardiac failure, the underlying causes of the problem
   and any precipitating factors.
3. Look for a pacemaker or defibrillator box.
4. Note wasting as a result of cardiac cachexia.
5. Take the blood pressure lying and standing. Treatment with ACE inhibitors and
   beta-blockers often results in mild hypotension.

Investigation

• Chest X ray
• ECG – look for arrhythmias, signs of ischaemia or recent or old infarction
• Bloods – Electrolytes (hypokalaemia, hyponatraemia), BNP, Hb  
• Echocardiography
• Cardiac MRI or CT
• Coronary angiograpy

Management

• Remove cause such as AF, Angio if CAD
• Control the failure: decrease physical activity, fluid restriction
• ACEi/ARB, ARNI
• Furosemide/Spironolactone
• Beta blocker – carvedilol, bisoprolol, nebivolol and extended release metoprolol
• Implanted defibrillator/cardiac resynchronization therapy
  • CRT indicated in sinus rhythm, LVEF < 35%, QRS > 120 and NYHA class 3 or 4
• Correct iron deficiency 

Hyperlipidaemia history

• D – Diagnosis:

1. 1. 1. When was this diagnosed?

• R – Risk:

1. 1. 1. Any family history?
      2. Alcohol? 

• P – Presentation:

1. 1. 1. Coronary artery disease?
      2. Pancreatitis?
      3. Hypothyroidism?

• P – Progression:

• I – Investigations:

1. 1. 1. Cholesterol?
      2. Triglyceride levels?
      3. LDL and HDL levels?

• M – Management:

1. 1. 1. Statins?
      2. Exetmibe?

• M – Monitoring

• C – Complications

• O – Outcome

Hypertension history

• D – Diagnosis:

1. 1. 1. When was it diagnosed?

• R – Risk:

1. 1. 1. T2DM? Hyperlipidemia? Fhx? CAD? Stroke?
      2. Obesity, excess alcohol consumption, lack of physical exercise and a high salt intake?
      3. Smoking?

• P – Presentation:

1. 1. 1. What were the BP readings?
      2. Ambulatory blood pressure recordings?

• P – Progression:

1. 1. 1. Any hospitalization?

• I – Investigations:

1. 1. 1. To rule out secondary causes do TFT, cortisol level

• M – Management:

1. 1. 1. Current and past antihypertensives?

• M – Monitoring

• C – Complications

1. 1. 1. Stroke? Heart failure? PVD? Renal failure?

• O – Outcome

Heart transplantation history

• D – Diagnosis:

1. 1. 1. When was cardiac failure diagnosed?
      2. When did heart transplant happen?

• R – Risk:

1. 1. 1. What is the cause of the cardiac failure? Eg: Cardiomyopathy, IHD, Rheumatic valvular heart disease, pulmonary HTN, cystic fibrosis, congenital heart disease?
      2. Previous MI or angina?

• P – Presentation: 

1. 1. 1. Presentation Sx when diagnosed
         1. What were your symptoms before surgery?
         2. Angina? Exercise tolerance?
         3. Hospital admission? Including any ICU admission requiring ionotropes?
      2. Interventions before transplant
      3. Transplant done at? 
      4. Any immediate post op complications?
         1. Any problems with surgery? 
         2. Any problem with rejection?

• I – Investigations:

1. 1. 1. Cardiac catheterization? Cardiac biopsy? Thoracotomies?
      2. Exercise stress tests? 
      3. Gated blood pool scans, before and after surgery?
      4. Endomyocardial biopsies? (routine to perform them at weekly intervals for the first 3 weeks after operation)

• P – Progression/Graft function:

1. 1. 1. Symptoms post transplantation?
      2. Rejection? Resembles an attack of pericarditis
         1. Stress dose steroids?
         2. Severe rejection is often treated with antithymocyte globulin or the murine monoclonal muromonab-CD3. Repetitive rejection may be treated with total lymphoid irradiation or methotrexate

• M – Management:

• Before transplant

1. 1. 1. 1. Medications – diuretics, ACEi, beta blockers, Amiodarone?
         2. Implanted defibrillator and antitachycardia pacemaker and resynchronisation device?
         3. If a ventricular assist device is required?

• After transplant

1. 1. 1. 1. Should no longer require anti failure treatment
         2. Immunosuppressive meds – Cyclosporine, Tacrolimus, mycophenolate

• Immunosuppression

1. 1. 1. Mycophenolate and SE: GI, Neutropenia
      2. Tacrolimus and SE: HTN, Tremors, hair loss, mood issues, renal impairment, hypomg
      3. Prednisolone
         1. Cushingoid
         2. Diabetes
         3. Osteoporosis
         4. GORD
         5. Skin thinning and easy bruising
   2. Infections/Malignancy 
      1. Issues with recurrent infections?
      2. Prophylaxis
         1. PJP – Bactrim
         2. EBV – Rx reduce immunosuppression or acyclovir
      3. Vaccinations
   3. 1. Malignancy? 
         1. Skin  Ca (BCC and Squamous cell carcinoma common)
         2. Lymphoproliferative disorder (PTLD)

• M – Monitoring/Follow up

• Cardiac catheterization done twice a year, Coronary artery intimal proliferation can cause ischaemic heart disease in the transplanted heart and also present with no pain

•  Endomyocardial biopsies are performed routinely and at any suggestion of rejection. 

1. 1. 1. Frequency of follow up with transplant team

• O – Outcome/Impact

1. 1. Able to go to work after transplant?
   2. Exercise tolerance improved?
   3. How does the family cope?
   4. Problems with multiple investigations and appointments

Cardiac arrhythmias history

• D – Diagnosis:

1. 1. 1. Since when has this been an issue?

• R – Risk:

1. 1. 1. Previous heart disease – IHD, VT, aortic stenosis, heart block
      2. AF risks: Age, HTN, valve disease, IHD, recent surgery, ASD, WPW, alcohol, PE, thyrotoxicosis

• P – Presentation:

1. 1. 1. Rapid irregular palpitations? – AF
      2. Rapid regular palpitations +/- dizziness terminated by Valsalva – SVT
      3. Rapid regular palpitations +/- dizziness +/- syncope – VT
      4. Bradycardia with syncope – heart block
      5. AF with syncope – sick sinus syndrome
      6. FHx of sudden death – long/short QT, Brugada, HOCM

• P – Progression:

• I – Investigations:

1. 1. 1. electrophysiological studies (EPSs), cardiac biopsy, cardiac MRI and CT

• M – Management:

1. 1. 1. Any antiarrhythmics?
      2. DC cardioversion?
      3. Catheter ablation
      4. AICD

• M – Monitoring

• C – Complications

• O – Outcome

 

Respiratory

Dyspnoea history

Diagnosis

• How long have you been SOB and is it getting worse? (Progressive)

Risk

• Do you smoke? pk years?
• Fhx of respiratory disease?
• Occupation? Pets?

Details of breathlessness. Find out:

1. Are you always SOB or only at times? – continuous, discrete or with stepwise episodes
2. Are you SOB at rest or on exertion? How much exertion? 
3. ET How much were you able to do before?  And ET now?
4. Any other triggers apart from exertion? Ask about exercise, cold, smoking and allergens.
5. Orthopnoea, paroxysmal nocturnal dyspnoea, ankle swelling

Associated symptoms. Ask about:

1. Symptoms suggesting a cardiac cause (exertional chest pain, orthopnoea, paroxysmal nocturnal dyspnoea, ankle swelling – which may also be due to cor pulmonale) we
2. Cough, with sputum (characteristics and volumes – large volumes suggest bronchiectasis) or dry (interstitial lung disease)
3. •Wheeze (asthma, COPD)
4. •Haemoptysis (lung cancer, pneumonia, pulmonary tuberculosis, bronchiectasis, pulmonary embolus, vasculitis, pulmonary haemorrhage)
5. Alarm symptoms for malignancy such as weight loss, anorexia, haemoptysis or hoarseness. 

Underlying lying conditions

COPD – D, I, M

Asthma – D, I, M

HF – D, I, M

• Frequency of exacerbations 
• Any previous hospitalizations including ICU?

Bronchiectasis history

History

• D – Diagnosis:

1. 1. 1. When was it diagnosed?
      2. When did respiratory problems begin? Childhood?

• R – Risk:

1. 1. 1. Whooping cough or measles as a child?

• P – Presentation/story:

1. 1. 1. Sx: Cough, sputum production, hemoptysis, dyspnoea, wheeze, sinusitis, recurrent pneumonia, weight loss, fever, anorexia, symptoms of HF
      2. LRTI with influenza and adenoviruses, Necrotizing bacteria such as Staph aureus, Klebsiella?
      3. History of cystic fibrosis, TB, HIV, Ig deficiency, primary ciliary dyskinesia
      4. Precipitating causes of hospital admissions?

• P – Progression:

• I – Investigations:

1. 1. 1. CT chest? Ciliary function studies? Sweat test?

• M – Management:

1. 1. 1. Physio? Postural  drainage? Antibiotics (as Rx and prophylaxis), bronchodilators, lung resection.
      2. Childhood immunisations. MMR?

• M – Monitoring

• C – Complications

• O – Outcome

1. 1. How does the disease affect patients’ life? With work, infertility, etc. 

Lung carcinoma history

• D – Diagnosis:

1. 1. 1. When was it diagnosed?

• R – Risk

1. 1. 1. Family history? Smoking History? Passive smoking? Occupational history?

• P – Presentation/Symptoms

1. 1. 1. How was the diagnosis made or suspected?
      2. Symptomatic or asymptomatic
      3. Duration of resp symptoms – haemoptysis, dyspnoea, increasing cough, chest pain
      4. Malignancy symptoms – weight loss, loss of appetite, fatigue, night sweats, pain 
      5. Type of lung ca?
      6. Any metastases?
   2. I – Investigation
      1. CXR, CT Scans
      2. Bronchoscopy, Sputum cytology
      3. Needle biopsy and thoracotomy 

• M – management

1. 1. 1. treatment offered and began

• C – Complications

1. 1. 1. SVC obstruction
      2. Horners
      3. Ectopic cushings, SIADH

• O – Outcome

1. 1. Patients understanding of diagnosis and prognosis
   2. Impact on work/home environments and ability to work, impact on dependents. 

 

COPD – Chronic obstructive Pulmonary Disorder History

• D – Diagnosis:

• R – Risk:

1. 1. 1. Smoking, FHx (Alpha-1 antitrypsin deficiency), asthma, occupational exposure

• P – Presentation/Progression:

1. 1. 1. How was it diagnosed?
      2. Sx now: cough, sputum, dyspnoea, wheeze, impaired ET, weight loss
      3. Precipitating causes of exacerbation: URTI, pneumonia, medication compliance, RV failure sx, currently smoking, OSA, GORD 

• I – Investigations:

1. 1. 1. FBE: Hb – look for polycythaemia
      2. ABG: Pa02 < 55
      3. Sputum MCS: usually grow Haemophilus influenzae, Streptococcus pneu-moniae or Moraxella catarrhalis during exacerbations and remissions.
      4. ECG: RV hypertrophy, multifocal atrial tachycardia
      5. CXR: Hyperinflation
      6. LFT: FEV1/FVC < 0.70 | – GOLD 4 < 30%
      7. Ddx:  Asthma, Bronchiectasis

• M – Management:

1. 1. 1. Cease smoking: Nicotine substitutes, counselling, meds such as bupropion
      2. Antibiotics: Amoxy or Doxy
      3. Bronchodilators: Beta agonists + long acting anticholinergic drugs + Inhaled steroids
      4. Steroid during exacerbation
      5. Pulmonary rehab
      6. Vaccinations: Flu + Pneumococcal
      7. Home oxygen
      8. Rx heart failure
      9. Lung transplantation 
      10. Bipap during exacerbations

• M – Monitoring

1. 1. 1. Do you see a respiratory specialist? How often?

• C – Complications

1. 1. 1. Hospital admissions with exacerbations including ICU

• O – Outcome

1. 1. Impact of COPD on work and social life 

Examination
– check for pursed lip breathing, prolonged expiration, use of accessory muscles
– cyanosis, polycythaemia
– reduced chest wall movement
– reduced breath sounds +/- wheeze
– early coarse inspiratory crackles
– Signs of RHF
– Cachexia
– Side effects of steroids

 

Sleep Apnoea History

• D – Diagnosis:

1. 1. 1. When was it diagnosed?

• R – Risk:

1. 1. 1. Obesity, HTN, Alcohol , medications, tonsil enlargement/surgery

• P – Presentation/Progression:

1. 1. 1. Problems with excessive daytime sleepiness and working during the day?
      2. Snoring?
      3. Apnoeic episodes?
      4. Morning headaches?
      5. Restless leg syndrome?
      6. Narcolepsy?

• I – Investigations:

1. 1. 1. Epworth sleepiness scale – score > 11
      2. Sleep study/Polysomnography

• M – Management:

1. 1. 1. CPAP?

• C – Complications

1. 1. 1. CV risk

• O – Outcome

1. 1. Effective family and work?

Examination

• BMI
• BP
• CV/Resp exam
• Neck

ILD History

• D – Diagnosis:

1. 1. 1. When was it diagnosed?

• R – Risk:

1. 1. 1. Smoking, Drugs, occupational, connective tissue disease? Radiaiton? Idiopathic? 

• P – Presentation/Progression:

1. 1. 1. Presenting Sx? Dry cough, dyspnoea, lethargy, malaise
      2. Systemic Sx: weight loss, fatigue, fever, rash, arthalgia
      3. Onset and duration of Sx

• I – Investigations:

1. 1. 1. HRCT

• M – Management:

1. 1. 1. Steroids, nintedanib, pirfenidone

• M – Monitoring/Control

1. 1. 1. Symptoms now

• C – Complications

• O – Outcome

Examination

• Clubbing
• Upper vs lower creps – fine, late inspiratory
• Systeic disease – sarcoid, scleroderma, RA

Pulmonary HTN History

History

• D – Diagnosis:

• R – Risk:

• P – Presentation/Progression:

• I – Investigations:

• M – Management:

• M – Monitoring

• C – Complications

• O – Outcome

Examination

Sarcoidosis History

History

• D – Diagnosis:

• R – Risk:

• P – Presentation/Progression:

• I – Investigations:

• M – Management:

• M – Monitoring

• C – Complications

• O – Outcome

Examination

Cystic fibrosis History

• D – Diagnosis:

• • • Age of diagnosis?

• R – Risk:

• • • Family history

• P – Presentation:

• • • Presenting Sx: Asymptomatic, meconium ileus, respiratory infections, failure to thrive
  • Progression
    • Baseline Sx:
      • Respiratory – cough, sputum, hemoptysis, wheeze, dyspnoea, asal polyps, sinusitis
        • daily sputum volume
        • Exercise ability
        • Frequency of exacerbation
      • Cardiac – cor pulmonale
      • DM –  cystic-fibrosis-related diabetes 
      • Gastrointestinal/liver 
        • diarrhoea, steatorrhea, malnutrition, bowel obstruction
        • Cirrhosis and portal hypertension – Jaundice and variceal bleeding

• Fertility

• I – Investigations:

• • • Genotype/DNA test – Eg: delta F508
    • Sweat test: Sweat chloride > 70
    • Recent FEV1
    • Sputum MCS bugs – any Burkhokderia, pesudomonas, Mycobacterium abcessus, staph

• M – Management:

• • • TRIKAFTA® (elexacaftor/tezacaftor/ivacaftor), any SE?
    • Respiratory Rx: Chest physio, devices, mucolytic drugs, antibiotics
    • GI Rx: Pancreatic enzymes
    • Family planning: IVF
    • Transplant discussions?
    • Adherence herence 

• M – Monitoring

• • • Specialist? Good relationship

• C – Complications

• • • No. of hospital admissions

• O – Outcome

• • Impact on life, work, relationships
  • CF association?

 

Tuberculosis History

• D – When was it diagnosed?
• R – Risks – Recent immigrant? HIV, Malnutrition, Alcohol
• P Presentation – Sx during presentation
  • Sx now – weight loss, sweats, fever, cough and bloody sputum, chest pain
• I – CXR, sputum, bronchoscopy, mantoux as screening tuberculin test
• M – What is the RIPE regimen? Any SE?
• C – Any complications? Reactivation of disease?
• O – impact on life, work, family, public health risk, how public health handles?

 

Lung transplantation History

• D – Diagnosis:

• • • When was the transplant?
    • How many lungs are transplanted?
    • Any other transplants? Heart?

• R – Risk:

• • • Indication, underlying lung disease? Emphysema (alpha 1 antitrypsin deficiency, CF, Pulm HTN, Eisenmenger’s)

• P – Presentation/Progression:

• • • Details of transplant ,
    • Procedure successful from patient of view?

• I – Investigations:

• • • Lung function test after transplant?
    • Biopsies?

• G – Graft function

• • • How are sx now?
    • Rejection? How were they managed?
      • Sx: Malaise, fever, dyspnea, cough
      • Ix: Infiltrates & pleural effusion on CSR, transbronchial biopsy

• M – Management:

• • • Medications now?
      • Prednisolone, Cyclosporine, Tacrolimus, Mycophenolate, Azathioprine with SE of each
      • Tac/Cyclosporine levels?
      • Any recent changes in dose?

• M – Monitoring

• • • Follow up with the transplant team?
    • Transplant nurse access after hours?

• C – Complications

• • • Immunosuppression complication
      • Infections? Organisms? 
      • Prophylaxis
      • Malignancy 
    • Disease complication
      • Stenosis of bronchial anastomosis? Rx with dilatation & stenting?

• O – Outcome

• • How have they coped?
  • Impact on life, work, family

Examination

 

Endocrinological 

Diabetic History

• D – Diagnosis

• • • Type – 1 or 2
    • When was it diagnosed, at what age?

• R – Risk

• • • – FHx, Obesity, HTN Steroids 

• P – Presentation

• • • Symptoms at onset? – polydipsia, polyuria, LOW, DKA

• I – Investigations

• • • Investigation at onset
    • If T1DM any antibodies – Anti-GAD, Anti-IAA, Anti-IA2, Anti ZnT8

• M – Management:

• • • Treatment initiated at diagnosis
    • Progression overtime and current treatment
      • OHG and any SE
      • Insulin – how much and when, who administers, how, any problems, rotate sites
    • Diabetic diet?

• M – Monitoring (Control)

• • • Who measures, how often and what times (pre or post prandial)
    • What levels are obtained? (range & average)
    • Recent HbA1c
    • Hypoglycemic/Hyperglycaemic episodes
      • How often
      • Associated symptoms – morning headaches, lethargy, night sweats 
      • Hospital admission
    • Follow up – GP, Endocrinologist, diabetic educator, Podiatrist

• C – Complications

• • • Macrovascular – CVA, IHD, PVD
    • Microvascular – Retinopathy, Nephropathy, Neuropathy, Autonomic dysfunction

• O – Outcome

• • Impact on life

Diabetic Examination

• BMI
• Vision
• Finger prick
• Abdo – insulin sites, hypertropy
• Lower limb neurology examination

Cushing Syndrome

History

• D – Diagnosis

1. 1. 1. When

• R – Risk

1. 1. 1. Primary – adrenal tumour
      2. Secondary – Pituitary tumours (Cushing disease) 
      3. Ectopic ACTH
      4. Exogenous – Steroids

• P – Presentation/Progression

1. 1. 1. Sx on diagnosis

• I – Investigations

1. 1. 1. Salivary cortisol

• 24 hour urinary cortisol

• Low/High dexamethasone test

• M – Management

1. 1. 1. Wean Steroids

• C – Complications

1. 1. 1. Adrenal insufficiency 
      2. Diabetes
      3. HTN
      4. Osteoporosis
      5. Mood
      6. Proximal myopathy

• O – Outcome

1. 1. Impact on life, hospitalizations
   2. Impact on looks

Examination

• Increased facial width Moon face
• Dorsal fat pad Buffalo hump
• Abdominal Striae
• Weight gain and central adiposity
• Easy bruising
• Skin thinning

 

Gastrointestinal

 

Inflammatory bowel disease History

• D – Diagnosis:

1. 1. 1. What type of IBD? When was it diagnosed?

• R – Risk:

1. 1. 1. Family history? NOD2 gene (Crohn’s), smoker

• P – Presentation/Progression:

1. 1. 1. Presenting symptoms – Bloody diarrhoea, fever, weight loss
      2. Extracolonic manifestations?

• I – Investigations:

1. 1. 1. Bloods? Imaging? Endoscopy?

• M – Management:

1. 1. 1. Treatment – Sulfasalazine, 5-ASA, Steroids, Azathioprine
      2. SE?
      3. Surgery? 

• M – Monitoring/Current control 

1. 1. 1. No of hospital admissions
      2. Frequency of follow up?

• C – Complications

1. 1. 1. UC Local – Toxic megacolon, perforation. Strictures, malignancy
      2. Crohn’s local – Fistula, obstruction, cancer
      3. Extracolonic manifestations
         1. Eyes – uveitis
         2. Mouth – apathous ulcers
         3. Skin – pyoderma gangrenosum
         4. Arthropathy
         5. Liver – PSC, cirrhosis

• O – Outcome

1. 1. Impact on life and work 

 

Colon Cancer History

• D – Diagnosis:

1. 1. 1. When was it diagnosed?

• R – Risk:

1. 1. 1. Family history?

• P – Presentation/Progression:

1. 1. 1. Change in bowel habits
      2. PR bleeding
      3. Anaemia
      4. Abdo pain
      5. Bowel obstruction

• I – Investigations:

1. 1. 1. Ct scans, PET scan, Scopes

• M – Management:

1. 1. 1. Chemo, surgery
         1. Chemo SE

• Stoma – output, how frequently changed, consistency, who manages?

• M – Monitoring

1. 1. 1. Surveillance

• C – Complications

1. 1. 1. Recurrence

• O – Outcome

1. 1. Impact of life and work

Chronic Liver Disease History

• D – Diagnosis:

1. 1. 1. When was it diagnosed?

• R – Risk:

1. 1. 1. Alcohol? Hepatitis? Drugs?

• P – Presentation/Progression:

1. 1. 1. Presenting Sx? – Ascites, Abdo pain, acute bleeding, encephalopathy 

• I – Investigations:

1. 1. 1. U/S
      2. CT Quad
      3. Liver biopsy
      4. Endoscopy for varices

• M – Management:

1. 1. 1. Non pharm – alcohol abstinence, fluid restriction, steroids, lactulose

• M – Monitoring

1. 1. 1. Sx now
      2. Frequency of monitoring 

• C – Complications

1. 1. 1. SBP – fever, abdo pain, altered mental state 
         1. Number of episodes
         2. Prophylactic abx?
      2. Esophageal varices
      3. Hepatorenal/pulmonary syndrome
      4. Hospital admissions with decompensation
      5. HCC?

• Tx consideration

1. 1. 1. Contraindications
         1. Malignancy
         2. Infection
         3. Alcohol
         4. HIV

• O – Outcome

1. 1. Impact of life and work

Examination

• Jaundice
• Tatoos
• Palmar erythema
• Ascites

Liver Transplantation History

• D – Diagnosis:

1. 1. 1. When was the transplant?

• R – Risk:

1. 1. 1. What was the underlying liver problem?
         1. Cirrhosis, PSC, hepatitis, wilson’s disease, alpha1 antitrypsin

• P – Presentation:

1. 1. 1. What type of transplant? – Alive or deceased?
      2. Type of match?
      3. Any surgical complications?
      4. Acute complications? Graft failure, technical problems, infections

• I – Investigations:

1. 1. 1. Cardiac and pulmonary tests
      2. Liver tests – rule out HCC

• Graft control

• Function now?

• Chronic rejection? Biliary stricture?  

• Management

1. 1. 1. What medications currently on 
      2. Any recent changes

• M – Monitoring

1. 1. 1. Who manages?
      2. How frequently

• C – Complication

• Disease complication 

• Immunosuppression

1. 1. 1. 1. Cyclosporin? SE: HTN, nephrotoxicity, gum hypertrophy, CNS effects
         2. Steroids? SE: weight gain, DM, Osteoporosis, GORD

• Infection/Malignancy 

1. 1. 1. 1. Any infections?
         2. Opportunistic infections – PJP, Candida, CMV
         3. Prophylaxis
         4. Malignancy – skin cam lymphomas

• O – Outcome

1. 1. Impact on life, work, mood. 

 

Haematological 

Bone Marrow Transplantation History

• D – Diagnosis:

1. 1. 1. When did you get the Bone marrow transplant?

• R – Risk:

1. 1. 1. What was the indication of the transplant?

• P – Presentation/Progression:

1. 1. 1. Type of transplant? Autologous vs Allogeneic
         1. Autologous – how were the stem cells harvested? (peripheral blood vs bone marrow aspirate)
         2. Allogenic: Do you know the donor? HLA status? Was it a close match?
      2. How long after transplant In hospital? Any immediate complications

• I – Investigations:

1. 1. 1. CV testing
      2. Cancer screen – skin checks

• Graft function 

1. 1. 1. Have Sx resolved? Prognosis?
      2. Engraftment? BM function? Neutrophils now

• M – Management:

1. 1. 1. Current medications?
      2. Platelets, bloods, Colony stimulating factor

• M – Monitoring

1. 1. 1. Who follows up and how often?

• C – Complications

1. 1. 1. Disease related complications?
      2. Chemo SE
      3. Immunosuppression SE
      4. GVHD? – Skin changes, diarrhoea, LFT deranged
         1. Risks of GVHD: previous blood products, pregnancy
         2. Rx of acute GVHD with steroids, antithymocyte globulin and mAB to T cells
         3. Chronic GVHD – after 3 months
      5. Infections – Bacterial, fungal, CMV
      6. Malignancy
      7. Recurrence of primary disease? Eg: Leukaemia

• Prevention

1. 1. 1. Prophylaxis
         1. GVHD prophylaxis: Pred, methotrexate, cyclosporin
         2. PJP, CMV prophylaxis
      2. Vaccinations

• O – Outcome

1. 1. Effect on life, work, family, finances, sterility

• Examination
  • Examine for signs of chronic GVHD. These include skin changes similar to those of scleroderma, dry eyes and mouth (sicca syndrome), alopecia and bronchiolitis oblit-erans (signs of airflow obstruction).
  • Assess lymph nodes
  • Asses liver + for ascites and spleen
  • Hypothyroidism 

Polycythaemia History

• D – Diagnosis:

1. 1. 1. When was it diagnosed?

• R – Risk:

1. 1. 1. Any family history?
      2. Any disease causing secondary polycythaemia? – smoking, COPD, OSA, PCKD

• P – Presentation/Progression:

1. 1. 1. What were the presenting sx?

• I – Investigations:

1. 1. 1. JAK2 V617F mutation?
      2. Erythropoietin levels?

• M – Management:

1. 1. 1. Phlebotomy – how often, how long
      2. Resolution of symptoms?

• M – Monitoring

1. 1. 1. Who follows you up and manages this?

• C – Complications

1. 1. 1. Any vascular complications? – TIA, Angina, PVD, budd-chiari
      2. Any bleeding?
      3. Peptic ulceration?
      4. Abdo pain?
      5. Gout?
      6. Pruritis

• Prevention?

• O – Outcome

Examination
– Splenomegaly

 

Chronic Myeloid Leukaemia History

• D – Diagnosis:

1. 1. 1. When was it diagnosed?

• R – Risk:

1. 1. 1. Any family history?

• P – Presentation/Progression:

1. 1. 1. What were the presenting sx?
         1. Fatigue, Malaise, LOW, Abdo discomfort, infection, thrombotic episodes

• I – Investigations:

1. 1. 1. Raised WCC
      2. Splenomegaly on imaging
      3. Blood film – blasts?
      4. BCR-ABL

• M – Management:

1. 1. 1. Allogeneic bone marrow transplant?
      2. Imatinib: SE – Hepatotoxicity, Myalgia, Fluid retention 
      3. Interferon

• M – Monitoring

1. 1. 1. Who follows you up and manages this?

• C – Complications

1. 1. 1. Sx from disease – – fever, infections, joint pain, bone pain, haemorrhage/thrombosis

• Prevention?

• O – Outcome

Examination
– Splenomegaly

 

Lymphoma History

• D – Diagnosis:

• • 1. When was it diagnosed?
    2. What type?
       1. Common in > 40 – diffuse large cell and follicular cell
       2. Common in < 40 – Hodgkin lymphoma

• R – Risk:

• • 1. Any family history?
    2. Klinefelter’s syndrome, HIV infection, congenital or acquired immune deficiency, use of immunosuppressive drugs or autoimmune disease (e.g. Sjögren’s syndrome)

• P – Presentation:

• • 1. P/W – palpable nodes, cough (mediastinal involvement), systemic Sx, bone pain

• I – Investigations:

• • 1. Imaging – PET/CT, MRI
    2. Lymph node biopsy

• M – Management

• • 1. Treatments undertaken
    2. Relapses
    3. Current Rx
    4. Bone marrow Transplant?

• M – Monitoring

• • 1. Prognosis? Patients understanding of it
    2. ECOG: Fully active (0) <50% in bed (2) >50% in bed(3) Bed bound (4) 

• C – Complications

• • 1. Complications of the disease? 
    2. Complications of Rx? –
       1. SE of Rx
       2. secondary malignancies, myelodysplastic syndromes, thyroid issues 

• O – Outcome

Examination: Lymph nodes, spleen, liver, anaemia

Multiple Myeloma Template

• D – Diagnosis:

1. 1. 1. When? 
      2. MGUS or Multiple Myeloma

• R – Risk:

1. 1. 1. Occupation (petroleum), radiation exposure 

• P – Presentation/Progression:

1. 1. 1. of note – MM diagnostic features – 
         1. >10% clonal plasma cells in the bone marrow
         2. CRAB features 
         3. Serum or urine paraprotein production
      2. CRAB features
         1. Sx – Hypercalcaemia, renal failure, anaemia, bone pain, infection (chest or urine), bleeding

• I – Investigations:

1. 1. 1. Biopsy of the marrow?
      2. Beta microglobulin 

• M – Management:

1. 1. 1. Medications – bisphosphonates, Thalidomide, Steroids
      2. Radiation
      3. Bone marrow transplant (happened or planned)

• M – Monitoring

1. 1. 1. Who manages and how often?
      2. Prognosis?

• C – Complications

1. 1. 1. Disease complications?
      2. Rx complications?
         1. Thalidomide/Borteomib/Lenalidomide SE – peripheral neuropathy, diarrhoea, liver, renal impairment

• O – Outcome

1. 1. Impact on life

Examination – Anaemia, weight loss, bony pain, infection

 

Rheumatological

Rheumatoid Arthritis 

• D – Diagnosis:

• • • When was it diagnosed? 

• R – Risk:

• • • Thx, other autoimmune conditions

• P – Presentation:

• • • P/W – fatigue, anorexia, pain, arthritis, morning stiffness that lasts for more than an hour

• I – Investigations:

• • • Antibodies – RF, Anti-CCP

• Progression

• • • Current disease activity 
    • Which joint is involved?
    • Non articular – Skin (raynauds, ulcers), eyes (dry eyes), neck pain, lungs, heart, renal, nerves (neuropathy), blood (anaemia), systemic

• M – Management:

• • • Analgesia
    • Methotrexate
    • Hydroxychloroquine
    • Cycloscoprin

• M – Monitoring

• • • F/U with rheumatologist, how often?

• C – Complications

• • • Methotrexate: hepatic, pulmonary toxicity, cytopneia
    • Leflunodamide: diarrhoea, alopecia
    • Cyclosporin: renal function, blood presure
    • Hydroxychlorquine: nausea, retinopathy
    • Sulfasalzaine: rash, liver, oligospermia
    • Anti TNF; reaction action of TB, lymphom 

• O – Outcome

• • Impact – hand function, pain

Examination

• general appearance for any steroid complications
• Hand exam
• Arms for nodules
• face 
• neck movements
• chest – lungs and heart
• abdomen – for splenomegaly 

SLE – Systemic Lupus Erythematosus

• D – Diagnosis:

• • • When was it diagnosed?

• R – Risk:

• • • Family Hx?
    • Any associations with HLA0DR2, HLA-DR3
    • Any drugs? Eg: Hydralazine, Anti-TNF

• P – Presentation

• • • Presented with?
      • Constitutional  Sx – Malaise, Fatigue, weight loss, N/V, clots
      • Joint Sx – Acute inflammatory polyarthritis of hands/feet
      • Dermatological Sx – rash, alopecia, raynauds 
      • Renal Sx – haematuria
      • Psych Sx = delirium, dementia
      • Cardio/Resp Sx – pericarditis
      • Haem Sx – Lymphadenopathy
      • GI Sx – N/V, diarrhoea
      • Recurrent miscarriage, history of PE, other clots
      • Sicca symptoms 
    • Disease progression to have any of the above Sx?

• I – Investigations:

• • • Antibodies – ANA, Anti-dsDN, Ant-Smith
    • Renal biopsy
    • MRI/Lumbar puncture  if CNS involvement 

• M – Management:

• • • Hydroxychloroquine, SE: Maculopathy – baseline eye exam then 5 yearly
    • Steroids 
    • Steroid sparing – Azathioprine, Methotrexate 
    • Rituximab 
    • Anticoagulation
      • Warfarin if venous clots
      • Warfarin + low dose Aspirin if Arterial
      • Clexane plus aspirin in childbearing age
    • Contraception
      • Progesterone only pill 
    • Pregnancy 
    • Sunscreen – protection from sunlight

• M – Monitoring

• C – Complications

• • • Disease complications?
      • CV risk
      • Lymphoma 
    • Renal complications?
      • Stage  1 & 2 – mesangial lupus nephritis does not requirement
      • Stage 3 – focal proliferative LN < 50% gloemruli affected 
      • Stage 4 – diffuse proliferative  > 50% glomeruli affected 
      • Stage 5 – membranous nephropathy 
      • Stage 6 – Advanced sclerosing LN
    • Pregnancy/fertility complications?
      • Lupus does not affect fertility
      • But we want lupus to be inactive for 6 months leading to pregnancy and particularly not have active renal disease
      • Can have Hydroxychloroquine and Azathioprine during pregnancy
      • Pregnancy can cause lupus flare
      • Risk of APLS so switch to LMWH and Aspirin
      • Lupus increases risk of pre-eclampsia so should be on Aspirin  

• O – Outcome/Prognosis

• • Prognosis?
    • 90% survival in 10 years
    • Poor prognosis: Renal, CNS, males do worse, asians for worse, 
    • Die early from bad kidney, CNS disease and infection as complication
    • Later death is from CV risk and steroids makes it worse 

Examination

• General – Cushoid
• Hands – rash, arthritis, raynauds, discoid lupus rash
• Arms – Proximal myopathy
• Face – Alopecia, scleritis, mouth ulcers, butterfly rash
• Chest – Cardio/resp exam
• Abdomen – hepatosplenomegsaly
• Legs – rash, proximal myopathy

Systemic Sclerosis (Scleroderma)

• D – Diagnosis:

• • 1. When was it diagnosed?

• R – Risk:

• • 1. Any family history?

• P – Presentation/:

• • 1. Presented with?
       1. Derm Sc – Raynauds, Sclerodactaly 
       2. Arthritis – Arthropathy 
       3. GI – dysphasia, diarrhoea
       4. Renal – Scleroderma renal crisis
       5. Resp Sx – ILD, Pulm HTN
       6. Cardiac – Arrythmia, HF
       7. Others – ED, Hypothyroidism, non melanoma skin cancer

• Progression

• • 1. 1. Sx now 

• I – Investigations:

• • 1. Bloods – ESR, Anaemia, B12, folate
    2. Antibodies – Anti-SCL 70 Anti centromere, Anti – RNA polymerase 
    3. Imaging – CXR, HRCT 

• M – Management:

• • 1. Sx management
       1. Raynauds – avoid smoking, cold weather, beta blockers, Nifedipine
       2. reflux – PPIT
       3. dry eyes – artificial tears
       4. Lung involvement – Cyclophosphamide 
       5. Renal involvement – Rx of HTN, ACEi

• M – Monitoring

• • 1. Who follows up
    2. Regular screening of ILD

• C – Complications

• • 1. Disease complications
    2. Treatment complications

• O – Outcome

• 1. Degree of disability – function at home, ability to work, finances
  2. Prognosis?

Examination

• General – Bird like fancies, Weight loss
• Hands – Sclerodactly, Calcinosis, Raynauds, telangectasia, fixed flexion deformity, hand function
• Face – Alopecia, dry eyes, dry mouth, telangectesia
• Chest – tight skin, CV exam, BP
• Leg – skin lesions 

 

Renal

Chronic kidney disease

• D – Diagnosis:

• • 1. When was it diagnosed?

• R – Risk:

• • 1. Diabetes, Hypertension, Glomerulonephritis, IgA nephropathy, analgesia, PCKD, Reflux nephropathy, Connective tissue (Scleroderma)

• P – Presentation

• • 1. Any Sx on diagnosis?
       1. Lethargy, loss of appetite, N/V, priorities, fluid retention
    2. eGFR then?

• Progression:

• • 1. Symptoms now?
    2. eGFR?

• I – Investigations:

• • 1. Bloods?
    2. Biopsy?

• M – Management:

• • 1. If dialysis has been discussed? If a patient iis eligible? Access?
    2. Transplant?

• M – Monitoring

• • 1. Who manages CKD and how frequently you see them?

• C – Complications

• • 1. During dialysis
    2. Anaemia/Acidosis
    3. Bone
    4. Cardiovascular
    5. Dialysis/access/diet
    6. Electrolytes
    7. Fluid
    8. TUI: Transplant/Infection/Uremic

• O – Outcome

 

Examination

• General appearance – body habitus
• Hands/Arms – Asterixis, fistulas, BP
• Face – eyes for anaemia, tongue for mucus membranes
• Chest – any scars, permacaths, heart and lungs
• Abdomen – palpable kidneys, scars
• Legs – oedema, neuropathy

ESRF History 

• D – Diagnosis:

• • 1. When was ESRF diagnosed?

• R – Risk:

• • 1. Reason for kidney failure

• P – Presentation

• • 1. How did you present it?

• I – Investigations:

• • 1. Any biopsies?

• M – Management:

• • 1. What Modalities, progression of them & any complications
       1. Peritoneal dialysis?
       2. Haemodialysis? Home or satellite
    2. Access, any complications of them
    3. Times – frequency of dialysis & goals each session
    4. Interdialytic weight gain and dry weight
    5. Urine output and fluid restriction
    6. Who drives to dialysis

• M – Monitoring

• • 1. How often do you see the renal team?

• C – Complications

• • 1. During dialysis – hypotension, cramps
    2. Anaemia/Acidosis
    3. Bone
    4. Cardiovascular
    5. Dialysis/access/diet
    6. Electrolytes
    7. Fluid
    8. TUI: Transplant/Infection/Uremic
       1. Any potential donors?

• O – Outcome

• 1. Impact of dialysis on QOL?

 

Examination

• General appearance – body habitus
• Hands/Arms – Asterixis, fistulas, BP
• Face – eyes for anaemia, tongue for mucus membranes
• Chest – any scars, permacaths, heart and lungs
• Abdomen – palpable kidneys, scars
• Legs – oedema, neuropathy

 

Neurology

Multiple Sclerosis History 

• D – Diagnosis:

• • 1. Sx onset?
    2. Diagnosed?

• R – Risk:

• • 1. FHx
    2. EBV
    3. HLA-DRB1

• P – Presentation

• • 1. Spastic paraparesis, hemiparesis
    2. Episodes of limb paraesthesia
    3. Visual problems
    4. Ataxia, dysarthria, tremor
    5. urinary/bowel incontinence

• I – Investigations:

• • 1. MRI
    2. LP – Oligoclonal bands
    3. Visual evoked potential
    4. Mcdonalds criteria

• P – Progression:

• Clinically isolated syndrome? – isolated episodes 

• Relapsing remitting? – relapses but stable between episodes

• Secondary progressive MS – Gradual progression of symptoms with distinct episodes

• Primary progressive MS – Increasing symptoms without distinct episodes

• Current function

• • 1. Current disability
    2. Social disability – work, finances, sex, relationships

• M – Management:

• • 1. Treatments tried?
    2. Supportive and Sx Rx
       1. Support groups
       2. Spasticity – baclofen
       3. Urinary urgency – Amitriptyline
    3. Immunosuppression/Immunomodulation
       1. Injectable
          1. Interferon – improves survival
          2. Glatiramer – Subcute
       2. Oral
          1. Fingolimod – oral
          2. Teriflunomide – oral
       3. IV/Mabs
          1. Natalizumab – potent
          2. Alemtuzumab – potent

• M – Monitoring

• • 1. Who manages and how often do you see them?

• C – Complications

• • 1. MS complication
    2. Rx complications
       1. Interferon: Hepatotoxicity, leukopenia
       2. Glatiramer – chest pain, SOB
       3. Natalizumab – PML – progressive multifocal encephalopathy
       4. Alemtuzumab – ITP
       5. Fingolimod – macular odema

• O – Outcome

• 1. Impact on life

Examination

• Examine cranial nerves – loss of visual acuity, RAPD, INO
• Lhermitte’s sign – ask to flex neck and check for shock like sensation in limbs
• Look for spastic paraparesis, posterior column loss, cerebellar sings
• NMO – sudden onset of visual loss and pain on eye movements + sensory disturbance in arm + bladder/bowel control

Myasthenia Gravis History 

• D – Diagnosis:

• • 1. When was it diagnosed?

• R – Risk:

• P – Presentation/Progression:

• • 1. Sx
       1. Ocular – diploid, drooping eyelids
       2. Bulbar – dysarthria, dysphagia
       3. proximal weakness
       4. difficult anaesthesia

• I – Investigations:

• • 1. Bloods: Anti-AChR antibodoies, Anti-musk antibodies
    2. EMG
    3. Thymoma Is – CT chest

• M – Management:

• • 1. Pyridostigmine 
    2. Steroids
    3. IVIG, plasma exchange
    4. Rituximab
    5. Thymectomy

• M – Monitoring

• C – Complications

• • 1. Myasthenia crisis
    2. SLE, RA
    3. respiratory involvement 

• O – Outcome

Examination

• Fatigue – eyelids (sustained upward gaze), bulbar (count back from 20), proximal weakness (hold arm up), chicken dance

• thymectomy scar

 

Others

Transplant History

• D – Diagnosis:

• • • When was the transplant?
    • What was transplanted?

• R – Risk:

• • • Indication?

• P – Presentation/Progression:

• • • Where? – relative or cadaveric
    • HLA/ABO status
    • CMV status
    • Any surgical problems
    • Any immediate complications?

• I – Investigations:

• • • Biopsies
    • Routine investigations

• G – Graft function

• • • Graft function now
    • Cr level and has it been rising or falling 
    • Complications of transplanted organ
      • Rejection? – fever, swelling and graft tenderness
        • Type
        • Sx
        • Rx

• M – Management:

• • • Medications now?
      • Prednisolone, Cyclosporine, Tacrolimus, Mycophenolate, Azathioprine
      • Tac/Cyclosporine levels?

• Any recent changes?

• M – Monitoring

• • • Follow up with the transplant team?
    • Transplant nurse access after hours?

• C – Complications

• • • Immunosuppression SE
      • Tacrolimus (levels b/w 5-10) – renal dysfunction, alopecia, HTN, tremor, HypoMg
      • Cyclosporine – gingival hypertrophy, hirsutism, tremor, gout
      • Mycophenolate – diarrhoea, leukopenia, infections
      • Sirolimus, Everolimus – delayed wound healing, proteinuria, hyperlipidemia
    • Infections? Organisms? – prophylaxis, vaccinations

• Prophylaxis

• • • • • Valganciclovir for CMV for 6 months post op
        • Bactrim for PJP for 12 months or forever sometimes

• Vaccinations

• • • • • Influenza
    • Malignancy
      • Ca screening

• P Prognosis 

• O – Outcome

• • How have they coped?
  • Impact on life, work, family

Examination

• Any tremors
• Skin – Squamous and BCC
• Cushingoid features
• Check gums
• Abdomen – scars, transplanted organ
• Vascular access – fistula
• Lungs

Falls History

• D – Diagnosis:

• • • Any falls? How many? When was the last one?
    • Frequency per month? Any change in frequency recently?

• P – Presentation/Progression:

• • • Any injuries? 
    • Any hospital admissions?
    • What were the circumstances? 
      • tripping, loss of balance, postural, nocturnal, indoors/outdoors?
      • Doing what? – toilet, rushing, standing, bending, gardening
      • Syncopal prior falls?
      • Loss of consciousness?
      • Complication post fall 

• R – Risk:

• • • Vision, pacemaker, gait aids, medications, problem with mobility (stroke, myopathy, arthritis)

• I – Investigations:

• M – Management:

• • • Anything done to prevent falls? Changed meds or gait aids?

• M – Monitoring

• C – Complications

• • • Osteoporosis, long lie, fear of falling, anticoagulation

• O – Outcome

• • Does not leave the house due to fear of falls?

 

HIV History

• D – Diagnosis

• • • When was it diagnosed?

• R – Risk:

• • • How was it acquired?
      • Sexual orientation, sexual habits – think about other STIs in these patients
      • IVDU – think about Hep A/B/C in these patients
      • Tattoos
      • Blood transfusions
    • Here or overseas

• P – Presentation:

• • • What were the presenting symptoms?
      • Seroconversion illness? – Fever, Rash, lymphadenopathy
      • OR AIDS-defining illness?
        • PJP, Kaposi sarcoma, Esophageal candidiasis, Mycobacterium avium (MAC), Non-Hodgkin lymphoma, CMV, Cryptococcosis, HIV encephalopathy, Toxoplasmosis 
      • OR Asymptomatic screening? Why was it tested?
    • Was it diagnosed early or late?
    • How was the diagnosis confirmed?
      • HIV – ELISA then Western blot to confirm – HIV PCR DNA
      • CD4 count < 200 or HIV-associated disease (CD4 at diagnosis?)
    • Any coinfections? – Hep B or C/TB (make is own issue)

• I – Investigations

• • • Current HIV viral load and CD4 count
      • At diagnosis and current
      • Nadir (Lowest CD4 count)
    • HIV genotype?
    • Other STIs – chlamydia, gonorrhoea
    • Other blood bourne – Hep B/C
    • Other investigations performed – MRIs, CT, LPs, BMAT, endoscopy
    • Ix for Complications
      • CMV Ab, toxoplasma antibody
      • CXR – cardiac or pulmonary complications
    • If CD4 <200 – Hep C RNA, cryptococcal antigen, stool for OCP
    • If CD4 < 100 – CMV PCR, mycobacterial cultures, fundoscopy, ECG

• Current Sx

• • • Any ongoing Sx – Neuro, ocular, mouth,  cardiac, respiratory, GI, renal, haem, derm 

• M – Management: Classify as antiretroviral naive, on first line, extensive drug resistance

• • • Current HAART regimen, how many have you tried?
      • Previous and current – start date and stop date
      • Resistance?
      • Adherence?
      • Drug side effects
        • Reverse transcriptase inhibitors – 
          • NRTIs – diarrhoea (poo), pancreatitis, peripheral neuropathy
          • NNRTIs – cognitive Sx, hepatitis, rash
        • Integrase inhibitors – headache, fatigue
        • Protease inhibitors – diarrhoea, hepatitis, insulin resistance
      • Specific SE
        • Abacavir – HLAB27, don’t use in IHD
        • Tenofovir – renal impairment, bone issue
    • CVD risk factor modification

• M – Monitoring

• • Who is involved – medical follow up social follow up – headaches, mood changes, fatigue

• C – Complications

• Opportunistic infections

1. 1. 1. Should have an idea about opportunistic infections from CD4 counts
         1. CD4 200-500: Herpes, pneumonia, candida, TB
         2. CD4 20-200: PJP, toxoplasmosi, cryptococcosis, Kaposi’s sarcoma, non-Hodgkin lymphoma, CNS lymphoma
         3. CD4 < 50: MAC, CMV retinitis, cryptosporidiosis
      2. Have you ever had any AIDS-defining infections or Malignancies?
         1. PJP?
         2. Toxoplasmosis?
         3. MAC?
         4. Kaposi’s sarcoma?
         5. Non Hodgkin Lymphoma
      3. Prophylaxis for opportunistic infections
         1. <200 – bactrim to prevent PJP
         2. <50 – azithromycin to prevent MAC
      4. Vaccinations

1. General Sx- fever, lethargy, weight loss – constitutional, cancer, infection
2. Neurological – cryptococcal meningitis, toxoplasmosis, Hodgkin symptoms, HIV dementia, multifocal leukoencephalopathy
3. Ocular – vision from CMV retinitis
4. Mouth – ulcers, gingivitis, hairy leucoplakia, candidiasis
5. Cardiac -dyspnoea, chest pain or palpitations due to myocarditis or pericarditis, angina
   1. Ask about risk factors and treatment for cardiovascular disease:
      1. known ischaemic heart disease – angioplasty, CABG
      2. smoking – awareness of risk
      3. cholesterol level – statin treatment
      4. family history of ischaemic heart disease
      5. diabetes
      6. hypertension – treatment.
6. Respiratory symptoms – concerns regarding PCP pneumonia, bacterial/fungal, TB
7. GI symptoms – cryptosporidium, mycobacterium, CMV, drug side effects
8. Renal – nephrotic syndrome
9. Dermatological – drug reactions, viral or fungal infections, Kaposi sarcoma
10. Haematological – anaemia, thrombocytopenia
11. Peripheral – peripheral neuropathy, myopathy

• O – Outcome

1. 1. Do people know the diagnosis?
   2. Impact on life – relationships, work, finances
   3. Sexual contacts and history

Long term management approach for HIV

• For HIV:
  • Viral load, CD4, LFTs and UEC regularly
• Comorbidities:
  • Regular STI screens, regular screens for other blood borne illnesses and appropriate treatment
• Complications:
  • Monitor for complications of drugs and treat including failure of therapy which may need a change of strategy
  • Regular monitoring for malignancy
  • Regular monitoring for opportunistic infections and prophylaxis for these Aggressive risk factor modification for CV risk factors – cholesterol, HbA1c, HTN, smoking cessation
• Social
  • Support for patient and support for partner
  • Education regarding safe injection and safe sex and PREP therapy

Polymyositis/Dermatomyositis History

History

• D – Diagnosis:

1. 1. 1. When was it diagnosed?

• R – Risk:

1. 1. 1. Any risk factors?

• P – Presentation:

1. 1. 1. How did you present?/How was it diagnosed?

• I – Investigations:

1. 1. 1. What investigations were done to diagnose it?

• P – Progression

1. 1. 1. Sx now
      2. Complications from the condition

• M – Management:

1. 1. 1. Meds/immunosuppression
      2. Any change in immunosuppression?
      3. Managed by/Follow up

• C – Complications

1. 1. 1. Immunosuppression side effects 
      2. Infections – prophylaxis, Vaccination
      3. Malignancy – ca screening 

• O – Outcome/Impact 

Examination

• Look for rash
• Arthritis

Obesity History 

• D – Diagnosis:

• • 1. Time of weight gain 

• R – Risk:

• • 1. Family hx of obesity
    2. Any meds?  – steroids, insulin, sulphonylureas, antipsychotics, anticonvulsants, TCA. 

• P – Presentation/Progression:

• • 1. Max weight/BMI -> Current weight/BMI
    2. Eating patterns – how many meals, what? Snacking? Tried any diets? What happened?
    3. Exercise? – what? How often for how long?

• I – Investigations: N/A

• M – Management:

• • 1. Attempts to lose weight and what’s been tried?

• C – Complications

• • 1. OA, OSA
    2. DM, CV risk
    3. Mobility 
    4. Mood
    5. Social life 

• O – Outcome

• 1. Would you like to lose weight?
  2. Insight?

Examination

• BMI
• Central obesity?
• Waist circumference 
• BP
• Cushingout features
• DM?