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elliptic's version from 2018-03-27 11:53

Pregnancy

Question Answer
SupplementsFolic acid 0.5mg/d (from 1m pre-conception to 3m post-conception), or 5mg in women at higher risk of neural tube defects (on antiepileptic, PMHx/FHx of congenital abnormalities, pre-pregnancy diabetes, BMI>30). Iodine 150mcg/day all the way through pregnancy and breastfeeding.
Routine pregnancy shedule of visits (& routine things to do)4 wkly until K28, 2 wkly to K36, then weekly to delivery. Check weight, BP, urine dipstick, peripheral oedema. Fundal height, FHR, position and movements. EPDS (<12 & >28 weeks).
Expected weight gainBMI<18.5=12.5-18; Normal BMI: 11.5-16; Overweight; 7-11.5; Obese=5-9kg. 0.5-2kg weight gain in first trimester, then linear weight gain through 2nd + 3rd trimesters.
First trimester tasks① Initial antenatal visit for education, bloods (before K10); ② dating scan if needed (K8-13); ③ +/- NIPT (from K9); ④ +/- combined first trimester screening (at K11-13: USS for NT, free bHCG, PAPPA); ⑤ OGTT if high risk, ⑥ EPDS. (Monthly visits throughout).
Second trimester tasks ① Morphology USS (K18-20) ② Routine OGTT (K26-28). (Monthly visits throughout).
Third trimester tasksEGBAP ① EPDS ② GBS screen (36 weeks if high risk). ③ Bloods (FBE, Rh ab titre; K28 & 36) ④ +/- Anti-D 625 IU (K28 & 34) ⑤ Pertussis vax (optimum protection at K28-32) (2-weekly visits start at K28. Weekly visits start at K36).
Food safety adviceHygeine, meats, dairy, thorough cooking, and caution with cats and gardening. ① HYGEINE: wash hands, utensils, surfaces before food prep; wash fruit + veg ② MEATS: avoid cold sliced meats, cold cooked chicken, pate, uncooked seafood ③ DAIRY: avoid soft serve ice cream & soft cheeses ④ HIGH TEMP: reheat leftovers to high temperature (to kill off listeria) and cook meat thoroughly (to kill off toxoplasma). ⑤ TOXOPLASMA: wash hands after touching pets/gardening. also use gloves if handling kitty litter or gardening
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COPDx part 1

Question Answer
Summarise the 'C' component of COPDxCase finding. Diagnose COPD if FEV1/FVC < 0.7; consider asthma or asthma overlap if 400ml improvement post bronchodilator. Exclude other conditions. Assess severity regularly.
Summarise the severity assessment of COPDMild: FEV1 60-80% pred; breathlessness on moderate exertion and recurrent chest infections but little effect on daily activities. Moderate: FEV1 40-59% pred; breathlessness on level ground, cough and sputum production, exacerbations requiring steroids and/or antibiotics. Severe: FEV1 <40% pred; dyspnoea on minimal exertion, daily activities severely curtailed; regular sputum production and chronic cough. Progress can also be monitored with COPD Assessment Test (CAT).
Summarise the 'O' component of COPDxOptimisating function. Pulmonary rehab. Regular exercise. Stepwise pharmacotherapy. Regular reviews. Managing comorbidities. Specialist referral if necessary.
Stepwise pharmacotherapy of COPDSABA or SAMA → LABA or LAMA → LABA + LAMA → if FEV1<50% pred AND 2+ exacerbations in 12 months, ICS/LABA + LAMA
Indications for specialist referralUncertainty, severity, or need for specialist treatments. UNCERTAINTY: Diagnostic uncertainty; unusual symtpoms (e.g. haemoptysis); age <40; unsure if suitable for pulmonary rehab; symptoms of dysfunctional breathing (dyspnoea with chest tightness, anxiety, dizziness). SEVERITY: rapid decline; persistent symptoms; chest infections more than annually, ankle oedema. SPECIALIST TREATMENT NEEDED: SpO2 <92% when stable. Bullous lung disease on CXR/CT. Suspicion of OSA (refer for sleep studies).
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COPDx part 2

Question Answer
Summarise the 'P' in COPDxPrevent deterioration: Smoking cessation. Immunise against pneumovax and influenza. Long term O2 therapy (refer to specialist if persisting SpO2 <92%).
Summarise the 'D' in COPDxDevelop a plan of care. Use clinical support teams. Self-management support. Support groups. Community services. End-of-life planning.
Summarise the 'x' in COPDxIf they're feeling unwell (harder to breathe/more coughing/more or thicker phlegm), increase SABA, eg. to 4-8 puffs q3-4hrly. If this is inadequate, commence oral pred 30-50mg daily for 5 days. If there's also a change in colour and/or volume of phlegm, start antibiotics for 5 days. Review in 2-5 days. Send to hospital if needed.
Indications for sending to hospital in an exacerbationMarked increased intensity of symptoms. New/worsening peripheral oedema. SOB worsening or at rest. High fever. Worsening comorbidities. Increased anxiety. And things you'd probably send anyone to hospital for: Hypoxaemia (SpO2<92% if not on home O2). Altered LOC. Chest pain. Inability to perform daily activities.
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Kidney Health Australia guidelines

Question Answer
Kidney health check: what to test, who to test.Test eGFR, UACR, and BP; repeat in 1-2y if normal (unless diabetes, htn). Who: 3 conditions, 2 family factors; 2 lifestyle factors. DM2; HTN; CVD. FHx of CKD; ATSI > 30y. Obesity; Smoking.
What to do with a new finding of GFR under 60Repeat in 7d. If >20% reduction → possible AKI, discuss with nephrologist. If stable → repeat twice within 3m → if 3+ reduced GFRs for >3m → CKD diagnosed.
What to do with a new finding of urine ACR elevated (and what counts as elevated).M>2.5, F>3.5 = microalbuminuria. Repeat twice within next 3m (preferably first morning voids) → if 2/3 elevated over 3m → CKD diagnosed.
Investigations for a new diagnosis of CKD ① All patients: FBC; fasting lipids/glucose; ESR/CRP; urine microscopy for dysmorphic RBC's, red cell casts, crystals; renal USS. ② If systemic dz: antiGBM, ANCA, ANA, ENA, complement. ③ If >40y and possible myeloma: serum + urine EPP. If at risk, HBV, HCV, HIV.
Indications for referral to a nephrologist① progressive CKD (sustained ↓GFR 25% or ↑creatinine 15) ② eGFR < 30; ③ persistent ACR > 30; ④ BP poorly controlled on 3 drugs
Yellow action Plan: who it applies to, and what to doeGFR > 60 with microalbuminuria or 45-59 without microalbuminuria. Annual check. ① BP, weight. ② UEC, eGFR, lipids, HbA1c if diabetic. ③ UACR. ④ Manage BP, lipids, sugars. ⑤ Lifestyle modification.
Orange action Plan: who it applies to, and what to doeGFR 30-59 with microalbuminuria or 30-44 with normaulbuminuria. 3-6 monthly check. As for yellow plan plus: ① calcium, phosphate, PTH if GFR < 45. ② Cardiovascular risk assessment, consider antiplatelet agent. ③ Assess for complications, eg: anaemia, electrolytes (acidosis, hyperkalaemia), osteoporosis, depression.
Red action Plan: who it applies to, and what to doMacroalbuminuria (any GFR) or eGFR < 30. 1-3 monthly check. ① FBC if anaemic. ② Referral. ③ Discuss advance care planning. ④ Avoid using non-dominant arm for venepuncture if considering dialysis.
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