Conditions List Flashcards

Question

What is polypharmacy?

Answer 1

The concurrent use of multiple medications in an individual

Answer 2

1: What matters to the patient - Patient understanding objectives of drug therapy, management of existing health conditions and prevention of future health problems 2: Identify essential drug therapy - Drugs that have essential replacement functions (eg levothyroxine) and drugs to prevent rapid symptomatic decline (eg drugs for Parkinson's disease, heart failure) 3: Does the patient take unnecessary drug therapy? - Review drugs with temporary indications, higher than usual maintenance doses and those with limited benefit - For remaining drugs verify that each has a function that matters to the patient, review preventative treatment to ensure the pt is able to continue taking the medication for the required time to benefit, see if any lifestyle changes can replace unnecessary drug therapy 4: Are therapeutic objectives being achieved? - Symptom control, biochemical/clinical targets, preventing disease/ exacerbation - Check adherence 5: Are there ADRs? - Check interactions, correct monitoring and dosage - Check side effects and lab markers, cumulative adverse drug effects and drugs that may be used to treat ADRs from other drugs 6. Is the drug therapy cost-effective - Consider more cost effective alternatives 7: is the patient willing and able to take the drug therapy as intended? - Correct form, dosing schedule, assistance if needed

Answer 3

Prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines use has been optimised and where the medicines are prescribed according to best evidence It is present when: (a) all drugs are prescribed for the purpose of achieving specific therapeutic objectives that have been agreed with the patient; (b) therapeutic objectives are actually being achieved or there is a reasonable chance they will be achieved in the future; (c) drug therapy has been optimized to minimize the risk of ADRs and (d) the patient is motivated and able to take all medicines as intended.

Answer 4

Present, when one or more drugs are prescribed that are not or no longer needed, either because: (a) there is no evidence based indication, the indication has expired or the dose is unnecessarily high; (b) one or more medicines fail to achieve the therapeutic objectives they are intended to achieve; (c) one, or the combination of several drugs cause inacceptable adverse drug reactions (ADRs), or put the patient at an unacceptably high risk of such ADRs, or because (d) the patient is not willing or able to take one or more medicines as intended.

Answer 5

Frailty is well defined as a ‘reduced ability to withstand illness without loss of function’. The Gold Standards Framework defines this further as: 1. Multiple co-morbidities with signs of impairment in day to day functioning 2. Combination of at least three of: - Weakness - Slow walking speed - Low physical activity - Weight loss - Self-reported exhaustion

Answer 6

The number needed to treat (NNT) is a measure used in assessing the effectiveness of a particular intervention. The NNT is the average number of patients who require to be treated for one to benefit compared with a control in a clinical trial. It can be expressed as the reciprocal of the absolute risk reduction. The ideal NNT is 1, where everyone improves with treatment: the higher the NNT, the less effective is the treatment in terms of the trial outcome and timescale. So if treatment with a medicine reduces the death rate over 5 years from 5% to 1% (very effective), the absolute risk reduction is 4% (5 minus 1), and the NNT is 100/4, (25).

Answer 7

Be aware that multimorbidity refers to the presence of 2 or more long-term health conditions, which can include: - defined physical and mental health conditions such as diabetes or schizophrenia - ongoing conditions such as learning disability - symptom complexes such as frailty or chronic pain - sensory impairment such as sight or hearing loss - alcohol and substance misuse.

Answer 8

- Consider assessing frailty in people with multimorbidity. - Be cautious about assessing frailty in a person who is acutely unwell. - Do not use a physical performance tool to assess frailty in a person who is acutely unwell. Primary care and community care settings When assessing frailty in primary and community care settings, consider using 1 of the following: - an informal assessment of gait speed (for example, time taken to answer the door, time taken to walk from the waiting room) - self-reported health status (that is, 'how would you rate your health status on a scale from 0 to 10?', with scores of 6 or less indicating frailty) - a formal assessment of gait speed, with more than 5 seconds to walk 4 metres indicating frailty - the PRISMA-7 questionnaire, with scores of 3 and above indicating frailty. Hospital outpatient settings When assessing frailty in hospital outpatient settings, consider using 1 of the following: 0 self-reported health status (that is, 'how would you rate your health status on a scale from 0 to 10?', with scores of 6 or less indicating frailty) - the 'Timed Up and Go' test, with times of more than 12 seconds indicating frailty - a formal assessment of gait speed, with more than 5 seconds to walk 4 metres indicating frailty - the PRISMA‑7 questionnaire, with scores of 3 and above indicating frailty - self-reported physical activity, with frailty indicated by scores of 56 or less for men and 59 or less for women using the Physical Activity Scale for the Elderly.

Answer 9

- Decreased quality of life and life expectancy - Increased treatment burden: Difficulties in understanding and self-managing condition as well as adherence to lifestyle changes - Mental health issues: Those with cognitive impairment are particularly vulnerable - Polypharmacy: Adverse drug events increase in prevalence as the number of chronic conditions increases - Negative impact on carers welfare

Answer 10

- Identify those who may benefit from the recognition of multimorbidity, opportunistically in routine care or through healthcare records - Patients may require a multimorbidity approach if they: Have difficulties with daily activities, are frail, are prescribed over 10 medications, or frequently seek emergency care services - Establish the extent of disease burden: Discuss mental health issues, wellbeing and the interaction between their health and quality of life - Investigate how their treatment burden affects their daily activities - Ask about social circumstances and assess their health literacy - Assess the adequacy of pain management particularly in chronic pain conditions - Frailty should be specifically assessed through the evaluation of gait speed, self-reported health status, or the PRISMA-7 questionnaire: The PRISMA-7 involves questions considering the age, sex, health problems, assistance required and walking aid use of the patient

Answer 11

- Reducing treatment burden and optimising care is the goal in managing comorbidity - Maximise the benefits of existing treatments - Offer alternative follow-up arrangements if they are struggling to meet them - Reduce the number of high risk medications being prescribed and consider the use of non-pharmacological treatments - Consider a 'bisphosphonate holiday' in those taking bisphosphonates for longer than three years as there is no consistent evidence of continued benefits after this point. Discuss stopping bisphosphonates after 3 years and include patient choice, fracture risk and life expectancy in the discussion. - Consider the use of screening tools such as STOPP/ START in older people to recognise medicine safety concerns: STOPP identifies medications where the risk outweighs the therapeutic benefits in certain conditions and START suggests medications that may provide additional benefits ie proton pump inhibitors for gastroprotection in patients on medications increasing bleeding risk - Especially consider stopping the use of medications such as NSAIDS, warfarin and aspirin in patients with peptic ulcer disease, and pay particular attention to the prescription of reno-toxic or renally cleared drugs in reduced renal function - Ask patients about the benefits and harms of their individual treatments, considering the overall prognostic benefit - Promote self-management through education and engagement strategies - Support carers and families of patients - Use the action plan to follow up with the patient at agreed points: NHS England recommends a yearly review of all medications for people aged over 65, however, medications should be reviewed periodically to ensure that patients are being informed, given adequate laboratory tests and that treatments are optimised

Answer 12

Increasing age Female sex Low socioeconomic status Tobacco and alcohol usage Lack of physical activity Poor nutrition and obesity

Answer 13

1 - Are you older than 85 years? 2 - Are you male? 3 - In general, do you have any health problems that require you to limit your activities? 4 - Do you need someone to help you regularly? 5 - In general, do you have any health problems that require you to stay at home? 6 - If you need help, can you count on someone close to you? 7 - Do you regularly use a cane, a walker or a wheelchair to move about?

Answer 14

- infection: particularly urinary tract infections - metabolic: e.g. hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration - change of environment - any significant cardiovascular, respiratory, neurological or endocrine condition - severe pain - alcohol withdrawal - constipation

Answer 15

- memory disturbances (loss of short term > long term) - may be very agitated or withdrawn - disorientation - mood change - visual hallucinations - disturbed sleep cycle - poor attention

Answer 16

- treatment of the underlying cause - modification of the environment - haloperidol 0.5 mg as the first-line sedative - management can be challenging in patients with Parkinson's disease, as antipsychotics can often worsen Parkinsonian symptoms *careful reduction of the Parkinson medication may be helpful *if symptoms require urgent treatment then the atypical antipsychotics quetiapine and clozapine are preferred

Answer 17

1. Non-pharmacological management NICE recommend offering 'a range of activities to promote wellbeing that are tailored to the person's preference' NICE recommend offering group cognitive stimulation therapy for patients with mild and moderate dementia other options to consider include group reminiscence therapy and cognitive rehabilitation 2. Pharmacological management - the three acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) as options for managing mild to moderate Alzheimer's disease - memantine (an NMDA receptor antagonist) is in simple terms the 'second-line' treatment for Alzheimer's, NICE recommend it is used in the following situation reserved for patients with *moderate Alzheimer's who are intolerant of, or have a contraindication to, acetylcholinesterase inhibitors *as an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer's *monotherapy in severe Alzheimer's 3. Managing non-cognitive symptoms - NICE does not recommend antidepressants for mild to moderate depression in patients with dementia - antipsychotics should only be used for patients at risk of harming themselves or others, or when the agitation, hallucinations or delusions are causing them severe distress

Answer 18

is relatively contraindicated in patients with bradycardia adverse effects include insomnia

Answer 19

- increasing age - family history of Alzheimer's disease 5% of cases are inherited as an autosomal dominant trait mutations in the amyloid precursor protein (chromosome 21), presenilin 1 (chromosome 14) and presenilin 2 (chromosome 1) genes are thought to cause the inherited form - apoprotein E allele E4 - encodes a cholesterol transport protein - Caucasian ethnicity - Down's syndrome

Answer 20

Pathological changes 1. macroscopic: - widespread cerebral atrophy, particularly involving the cortex and hippocampus 2. microscopic: - cortical plaques due to deposition of type A-Beta-amyloid protein and intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein - hyperphosphorylation of the tau protein has been linked to AD 3. biochemical - there is a deficit of acetylcholine from damage to an ascending forebrain projection Neurofibrillary tangles - paired helical filaments are partly made from a protein called tau tau is a protein that interacts with tubulin to stabilize microtubules and promote tubulin assembly into microtubules - in AD are tau proteins are excessively phosphorylated, impairing its function

Answer 21

Normal gait involves: - The neurological system - basal ganglia and cortical basal ganglia loop. - The musculoskeletal system (which must have appropriate tone and strength). - Effective processing of the senses such as sight, sound, and sensation (fine touch and proprioception). As individuals get older they are more likely to experience medical problems affecting these systems, which leads to gait abnormalities and increases the risk of falls.

Answer 22

Falls often occur due to a range of factors and individuals who have fallen previously are at a significantly higher risk of falling again. Other risk factors include: - Lower limb muscle weakness - Vision problems - Balance/gait disturbances (diabetes, rheumatoid arthritis and parkinson's disease etc) - Polypharmacy (4+ medications) - Incontinence - >65 - Have a fear of falling - Depression - Postural hypotension - Arthritis in lower limbs - Psychoactive drugs - Cognitive impairment Some studies have shown that individuals with 4 or more risk factors have up to a 78% chance of falling It is not possible to remove all risk factors but it is important to limit these where possible.

Answer 23

It is important to establish the following from the history: - Where was the patient when they fell? - When did they fall? - Did anyone else see the patient fall? (collateral history) - What happened? Were there any associated features before/during/after - Why do they think they fell? - Have they fallen before? - Systems review - Past medical history (especially issues related to balance/sight/gait) - Social history

Answer 24

Nitrates Diuretics Anticholinergic medications Antidepressants Beta-blockers L-Dopa Angiotensin-converting enzyme inhibitors - (ACE) inhibitors

Answer 25

Benzodiazepines Antipsychotics Opiates Anticonvulsants Codeine Digoxin Other sedative agents

Answer 26

Investigations to consider Bedside tests - Basic observations, blood pressure, blood glucose, urine dip and ECG Bloods - Full Blood Count, Urea and Electrolytes, Liver function tests and bone profile Imaging - X-ray of chest/injured limbs, CT head and cardiac echo

Answer 27

Turn180 is a clinically useful test of dynamic postural stability suitable for assessing frail elderly people. Previous research indicates that people who take more than four steps to complete a 180° turn have an increased risk of falling compared with people who take four steps or less.

Answer 28

It uses the time that a person takes to rise from a chair, walk three meters, turn around 180 degrees, walk back to the chair, and sit down while turning 180 degrees. During the test, the person is expected to wear their regular footwear and use any mobility aids that they would normally require. The TUG is used frequently in the elderly population, as it is easy to administer and can generally be completed by most older adults. One source suggests that scores of ten seconds or less indicate normal mobility, 11–20 seconds are within normal limits for frail elderly and disabled patients, and greater than 20 seconds means the person needs assistance outside and indicates further examination and intervention. A score of 30 seconds or more suggests that the person may be prone to falls.

Answer 29

Frailty = A syndrome characterized by diminished strength, endurance and physiological function which increases the individual’s vulnerability to dependency and death. Frailty correlates with increasing age, disease and disability. Frailty Phenotype The Fried model defines frailty as the presence of three or more of: - Unintentional weight loss - Weakness evidenced by poor grip strength - Self reported exhaustionSlow walking speed - Low level of physical activity Individuals with one or two characteristics = pre-frail Phenotypic frailty is predictive of a higher risk of falls, hospitalization, disability and death

Answer 30

The frailty index is a count of health deficits i.e. the more deficits the frailer the person and the greater the risk of deterioration and death. - Best known index is Rockwood Frailty Index - Deficits comprise of symptoms, signs, diseases, disabilities and investigation findings – each one carries same weighting Ratio is calculated by: Number of deficits / Total number of deficits considered - Higher scores on the index have an increased risk of deterioration in health, institutionalization and death *Very fit = <0.09 – robust, active, energetic, motivated *Well – no active disease and exercise occasionally *Managing well – medical problems are well controlled but not regularly active beyond walking *Vulnerable – symptoms limit activities, tired during day * Mildly frail = 0.27 – need help for high order ADLs e.g. finance * Moderately frail – need help with house keeping and bathing *Severely frail = 0.42 – completely dependent for personal care, not at high risk of dying *Very seriously frail – completely dependent, approaching end of life *Terminally ill – life expectancy <6 months but may not be evidently frail Limitation is that detailed measurements and collation of patient data is needed.

Answer 31

Individuals who are frail have: - Increased inflammation – e.g. CRP, IL6, factor VIII and fibrinogen - Elevated insulin and glucose levels in fasting state - Low albumin - Raised D dimer and alpha anti-trypsin - Low vitamin D levels

Answer 32

1. Physical activity - Exercises focusing on strength and balance 2. Protein-calorie supplementation 3. Vitamin D supplements 4. Minimization of polypharmacy as this predisposes to frailty

Answer 33

Distribution With ageing, total body fat increases, therefore increasing the volume of distribution for fat soluble drugs Total body water decreases, decreasing the volume of distribution of water soluble drugs Serum albumin decreases which increases the effects of albumin bound drugs as the levels of unbound drugs increases Metabolism Reduced liver volume and enzyme activity in older people leads to reduced hepatic metabolism To prevent toxic accumulation, doses should be reduced or the dosing interval increased Elimination Changes in GFR can decrease the excretion of drugs from the kidneys To prevent toxic accumulation, doses should be reduced or the dosing interval increased

Answer 34

Pressure ulcers develop in patients who are unable to move parts of their body due to illness, paralysis or advancing age. They typically develop over bony prominences such as the sacrum or heel. The following factors predispose to the development of pressure ulcers: - malnourishment - incontinence - lack of mobility - pain (leads to a reduction in mobility)

Answer 35

The Waterlow score is widely used to screen for patients who are at risk of developing pressure areas. It includes a number of factors including body mass index, nutritional status, skin type, mobility and continence.

Answer 36

Grading of pressure ulcers - the following is taken from the European Pressure Ulcer Advisory Panel classification system. Grade 1 - Non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin Grade 2 - Partial thickness skin loss involving epidermis or dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister Grade 3 - Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Grade 4 - Extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures with or without full thickness skin loss

Answer 37

- a moist wound environment encourages ulcer healing. Hydrocolloid dressings and hydrogels may help facilitate this. The use of soap should be discouraged to avoid drying the wound - wound swabs should not be done routinely as the vast majority of pressure ulcers are colonised with bacteria. The decision to use systemic antibiotics should be taken on a clinical basis (e.g. Evidence of surrounding cellulitis) - consider referral to the tissue viability nurse - surgical debridement may be beneficial for selected wounds

Answer 38

Frontotemporal dementia Only consider for vascular dementia if there is suspected comorbid Alzheimer’s disease, Parkinson’s disease dementia or dementia with Lewy bodies.

Answer 39

The hip joint is stabilised by a capsule, which is formed of three ligaments: the iliofemoral, ischiofemoral and pubofemoral ligaments. The femoral head receives blood supply from three arterial sources: - Nutrient arteries inside the bone - Ligamentum teres - The femoral circumflex arteries: encircle the femoral neck on top of the capsule Causes of neck of femur fractures: The majority of neck of femur fractures occur in older patients because of low-energy trauma (e.g. a fall from standing height). Other causes of neck of femur fractures include: - High energy trauma: may cause neck of femur fractures in younger patients - Pathological fractures: a fracture in a diseased bone (due to a tumour or infection) - Reduced bone mineral density: osteopenia and osteoporosis. May be seen in younger patients due to long-term corticosteroid use, alcohol consumption or malnutrition. - Stress fractures: less common

Answer 40

The classification of neck of femur fractures is used to guide management. Fractures can be classified by anatomical location or by the degree of displacement or angulation. 1. Anatomical location - A neck of femur fracture occurring proximal to the intertrochanteric line is intracapsular and involves damage to the joint capsule. As a result, the blood supply from the femoral circumflex arteries and nutrient arteries inside the bone are disrupted. The only intact artery supplying the femoral head in this situation is the artery within the ligamentum teres which is not enough to keep the femoral head viable. This can ultimately lead to avascular necrosis. As a result, intracapsular fractures have a high risk of avascular necrosis of the femoral head and non-union of the fracture. - Extracapsular fractures are below the intertrochanteric line. These typically include intertrochanteric and subtrochanteric fractures, where the joint capsule is not damaged and the blood supply to the fracture site is sufficient, leading to better fracture healing and an improved prognosis. - Pathological fractures tend to be in the subtrochanteric region, which is subject to the most stress. 2. Garden classification The Garden classification classifies fractures according to the degree of displacement as seen on an AP radiograph: Stage I: incomplete fracture line or impacted fracture Stage II: complete fracture line, non-displaced Stage III: complete fracture line, partial displacement Stage IV: complete fracture line, complete displacement 3. Pauwels classification The Pauwels classification classifies fractures according to the angle of the fracture line from horizontal: Type I: between 0 and 30 degrees Type II: between 30 and 50 degrees Type III: more than 50 degrees

Answer 41

- Age (≥65 years in women and ≥75 years in men) - History and risk factors of osteoporosis including menopause, amenorrhoea, smoking, excessive alcohol or caffeine intake, physical inactivity, long-term or high-dose corticosteroid use - Previous fragility fracture - History of falls - Poor nutrition - Low body mass index (<18.5kg/m2) - Dementia - Visual impairment: which increases the risk of falls and subsequently fractures - History of tumours (primary or secondary bone tumours, breast, bowel, prostate, kidney, lung, thyroid tumours)

Answer 42

Typical symptoms of neck of femur fractures include: - Pain: in the hip, groin or knee - Unable to weight-bear - Decreased or painful mobility of the affected hip Other important areas to cover in the history include: Past medical history: previous history of cancer, bone tumours, fragility fractures, cognitive impairment, and other co-morbidities Drug history: medications may cause osteoporosis (e.g. corticosteroids) or have contributed to the fall (e.g. sedatives/hypnotics, antidepressants, diuretics, beta-blockers) Social history: lifestyle habits, home situation, living environment, activities of daily living Frailty scoring: using the Clinical Frailty Scale, according to the patient’s pre-morbid function Clinical examination Where a neck of femur fracture is suspected, an examination of the hip is necessary. However, excessive movement of the hip should be avoided as this can further displace the fracture. Typical clinical findings in neck of femur fracture include: - The affected leg is shortened, externally rotated and abducted - Palpation of the hip produces pain - The patient is unable to perform a straight leg raise (useful for discerning occult hip fractures) - Pain on gentle internal and external rotation of the affected leg (log roll test) - Soft tissue symptoms: bruising and swelling in and around the hip area

Answer 43

Investigations are performed to confirm a fracture, investigate the underlying cause, and assess for complications. 1. Bedside investigations - ECG: look for arrhythmias and coronary events that may have precipitated a fall. 2. Laboratory investigations - Baseline blood tests: FBC, U&E, coagulation screen - Creatinine kinase: to look for rhabdomyolysis (if the patient had been on the floor for a long time) - Urinalysis: to assess for urinary tract infection or hyperglycaemia - Group and save: blood loss from a neck of femur can be significant and a blood transfusion may be required 3. Imaging - X-rays: AP pelvis and lateral hip are the first-line imaging investigation. In patients with a history of malignancy, it’s recommended to obtain a full-length femoral X-ray looking for metastases and pathological fractures. - MRI: the gold standard investigation to exclude a hip fracture. MRI is especially useful for detecting fractures not seen on plain X-ray. - CT: If MRI is not available, a CT hip can be performed. CT is recommended in patients with greater trochanteric fractures (as 20% of greater trochanteric fractures extend into the femoral neck). 4. Other investigations In the case of a suspected pathological fracture caused by bony metastases, the femoral head is surgically removed during surgery and sent to pathology to ascertain the histological origins and to help identify the primary tumour.

Answer 44

1. Initial management - Analgesia: paracetamol, opioids and iliofascial/femoral nerve blocks. NSAIDs should not be used. - Intravenous access: for fluid resuscitation, blood transfusion and the administration of medications. - Assess and manage complications to prevent delays in surgical management (e.g. correct anaemia, anticoagulation, volume depletion and infection). - Elderly patients must also be under joint care with an orthogeriatrician. 2. Surgical management - The principles of surgical management are urgent reduction and internal fixation followed by early mobilisation. - Patients should have surgery within 36 hours of admission. Benefits of early surgery include higher rates of independent living, lower rates of non-union, shorter hospital admission, reduced pain scores, lower rates of complications and reduced 30-day and 1-year mortality rates. - Early mobilisation helps to prevent post-operative complications including venous thromboembolism, pressure ulcers, bronchopneumonia and other problems arising from prolonged immobility. *Intracapsular fractures In younger (<65-years-old), or physiologically fit patients, the femoral head should be rescued. Cannulated screws or a dynamic hip screw can be inserted. Cannulated screws involve a set of screws being driven into the femoral head across the fracture which stabilises the fracture. A DHS is a dynamic plate screwed across the fracture line into the femoral head. A DHS permits organised collapse of the fracture when the patient weight-bears. This improves fracture healing and union. In older patients, a total or hemi hip arthroplasty is recommended. This involves the removal of the femoral head and insertion of a prosthetic replacement. The acetabulum can also be reinforced with a socket in the context of significant osteoarthritic disease. *Extracapsular fractures For extracapsular fractures, internal fixation is favourable with DHS or trochanteric femoral intramedullary nailing with screws entering the femoral head. Multi-fragmentary fractures require more complex fixation due to instability.34 3. Non-operative management Although surgical management is the first-line management option, some patients may not be suitable for surgical intervention. Indications for non-operative management include: - Patients that are too unwell to undergo surgery - Short life expectancy - Delayed presentation or diagnosis of fracture with signs of healing - Immobile patients - Patients who decline surgery These patients can be managed conservatively through casts, splints and traction. Periodic X-rays of the affected hip are necessary to guide management. 4. Post-operative management The aims of post-operative management are to enhance recovery, promote early mobilisation and prevent future fractures and complications. - Analgesia - Rehabilitation - Falls risk assessment - Dietetic assessment - Early mobilisation - Axial bone densitometry: Assess for osteoporosis and offer anti-resorptive therapy to reduce risk of future fragility fractures. - Antibiotic prophylaxis: To prevent surgical site infections a significant cause of mortality. - Thromboembolism prophylaxis In the United Kingdom, if a hip replacement has been performed the details must be registered with the National Joint Registry. In addition, patients should be referred for assessment and management of osteoporosis if they have suffered a fragility fracture from low-energy trauma.

Answer 45

Once transient loss of consciousness has been ruled out, it is important to complete a full falls risk assessment. This is indicated in order to identify any causative features especially as older people are likely to have multiple co-existing risk factors. Although priority should be to treat any underlying medical cause (e.g. pacemaker if complete heart block), all causes should be addressed where possible. Due to the complex aetiology, it is important to continue to search for possible risk factors and causes of falls even when one has been found. 1. Gait - Physiotherapy 2. Visual problems - Eye test and ensure wears glasses 3. Hearing difficulties - Remove earwax, Hearing assessment 4. Medications review - Reduce unnecessary medication 5. Alcohol intake - Alcohol cessation advice, Alcohol service referral 6. Cognitive impairment - Referral to a psychiatric team 7. Postural hypotension - Review medication, Improve hydration 8. Continence - Treat or rule out infections, Continence assessment 9. Footwear - Ensure good fitting footwear 10. Environmental hazards - Turn on lights, Take up rugs

Answer 46

Osteoarthritis is the result of active, sometimes inflammatory but potentially reparative processes, rather than the inevitable result of trauma and aging. It is characterised by: -Progressive destruction and loss of articular cartilage with an accompanying periarticular bone response -The exposed subchondral bone becomes sclerotic, with increased vascularity and cyst formation -Attempts at repair produce cartilagenous growth at the margins of the joints, which later become calcified (osteophytes) -Several mechanisms have been suggested for the pathogenesis: 1. Metalloproteinases eg Stromalycin and collagenase, secreted by chrondrocytes degrade collagen and proteoglycans 2. IL-1 and TNF-alpha stimulate metaloproteinase production and inhibit collagen production 3. Deficiency of growth factors such as insulin-like growth factor and transforming growth factor impairs the matrix repair 4. Genetic susceptibility (35-65% influence) from multiple genes rather than a single gene defect, mutations for the gene for type 2 collagen have been associated with early polyarticular osetoarthritis Most osteoarthritis is primary with no obvious predisposing factor Secondary osteoarthritis occurs in joints that have been damaged in some way or are congenitally abnormal

Answer 47

KEY: Joint pain, relieved by movement and made worse by rest. Morning stiffness is less than 30 minutes SYMPTOMS: -Gradual onset usually beginning with one or a couple of joints. -Earliest symptom is pain, usually described as aching and is usually worsened by weight-bearing and relieved by rest -Stiffness follows awakening or inactivity but lasts less than 30 minutes and lessens with movement -Tenderness, crepitus and grating sensation -Can get locking and catching as a result of intra-articular loose bodies or abnormal menisci -Stiffness occurs after rest (gelling) SIGNS: -As osteoarthritis progresses, joint motion becomes restricted -Joint swelling, Joint enlargement ultimately occurs due to proliferation of cartilage, bone, ligament, tendon, capsules and synovium along with varying amounts of joint effusion -Synovitis which can present as effusion, warmth and synovial thickening -Periarticular tenderness -Bouchard’s (PIP) and Heberden’s (DIP) nodes -Joints most commonly affected: DIPs and PIPs, 1st CMCJ,1st MTPJ cervical and lumbar spine, hip, knee -Joint instability -Muscle weakness or wasting around the affected joint

Answer 48

GOLD STANDARD/ DIAGNOSTIC: -Usually diagnosed from the history if a person is over 45 AND has activity-related joint pain AND has either no morning joint related stiffness or morning stiffness that lasts no longer than 30 minutes -Plain Xray: Diagnostic features are 1. Osteophytes 2. Joint space narrowing 3. Bone cysts 4. Subarticular sclerosis OTHERS: -MRI: may be useful to distinguish other causes of joint pain -Blood tests: normal in osteoarthritis but should be checked for abnormalities which may indicate other diagnoses (do before starting patients on long term NSAIDs) -Joint aspiration to exclude septic arthritis and gout

Answer 49

1st LINE: Medication: 1. Paracetamol is the initial drug of choice for pain relief. Then go up the analgesic ladder: weak opioid in addition to paracetamol (usually codeine). NSAIDs can be used either orally or topically but they should be in short courses rather than continuously. 2. Intra-articular corticosteroid injections which produce short-term improvement when there is painful joint effusion. Systemic corticosteroids are not used 3. Topical capsaicin has been recommended as a treatment option Surgery: 1. Joint replacement: particularly total hip and knee replacement. Have transformed the management of severe, symptomatic OA. Yields reduced pain and stiffness with an associated increase in function and mobility ADJUVANT THERAPY: Physical measures: -Physiotherapy -Heat or ice packs -Bracing devices, joint supports and insoles -Walking stick -Acupuncture has been shown to help knee arthritis

Answer 50

The World Health Organization (WHO) provide definitions based on the T-score of the femoral neck, measured on a DEXA scan. The T-score is the number of standard deviations the patient is from an average healthy young adult. A T-score of -1 means the bone mineral density is 1 standard deviation below the average for healthy young adults. Normal: More than -1 Osteopenia: -1 to -2.5 Osteoporosis: Less than -2.5 Severe Osteoporosis: Less than -2.5 plus a fracture

Answer 51

Bone mineral density (BMD) is measured using a DEXA scan (dual-energy x-ray absorptiometry). DEXA scans are a type of x-ray that measures how much radiation is absorbed by the bones, indicating how dense the bone is. The bone mineral density can be measured anywhere on the skeleton, but the femoral neck reading is most important. Bone density can be represented as a Z-score or T-score. The Z-score is the number of standard deviations the patient is from the average for their age, sex and ethnicity. The T-score is the number of standard deviations the patient is from an average healthy young adult. The T-score is used to make the diagnosis.

Answer 52

- Older age - Post-menopausal women (Oestrogen is protective against osteoporosis but drops significantly after menopause. Hormone replacement therapy (HRT) is protective against osteoporosis.) - Reduced mobility and activity - Low BMI (under 19 kg/m2) - Low calcium or vitamin D intake - Alcohol and smoking - Personal or family history of fractures - Chronic diseases (e.g., chronic kidney disease, hyperthyroidism and rheumatoid arthritis) - Long-term corticosteroids (e.g., 7.5mg or more of prednisolone daily for longer than 3 months) - Certain medications (e.g., SSRIs, PPIs, anti-epileptics and anti-oestrogens [Tamoxifen is a selective oestrogen receptor modulator (SERM) used to treat breast cancer. It blocks oestrogen receptors in breast tissue but stimulates oestrogen receptors in the uterus and bones. It helps prevent osteoporosis but increases the risk of endometrial cancer. Raloxifene is a SERM used to treat osteoporosis (but not breast cancer in the UK)])

Answer 53

The NICE clinical knowledge summaries (April 2023) recommend assessing: - Anyone on long-term oral corticosteroids or with a previous fragility fracture - Anyone 50 and over with risk factors - All women 65 and over - All men 75 and over The 10-year risk of a major osteoporotic fracture and a hip fracture can be calculated using either: - QFracture tool (preferred by NICE) - FRAX tool (NICE say this may underestimate the risk in some patients) Patients are categorised as low, intermediate or high risk based on the risk calculator. For QFracture, this is based on the percentage, and patients above 10% are considered for a DEXA scan. For FRAX, this is based on the NOGG guideline chart (linked to on the online FRAX tool), which advises whether to arrange a DEXA scan or start treatment. These suggestions do not apply to specific groups. For example, NICE CKS (April 2023) suggest: A DEXA may be arranged without calculating the risk in patients over 50 with a fragility fracture Treatment may be started without a DEXA in patients with a vertebral fracture

Answer 54

1. The first step is to address reversible risk factors. For example, increase physical activity, maintain a healthy weight, stop smoking and reduce alcohol consumption. 2. The second step is to address insufficient intake of calcium (less than 700mg per day) and inadequate vitamin D (e.g., limited sun exposure) with additional: - Calcium (at least 1000mg) - Vitamin D (400-800 IU) 3. Bisphosphonates are the first-line treatment for osteoporosis. They are recommended for patients with osteoporosis based on a DEXA scan. They are considered in patients on long-term steroids. They work by interfering with the way osteoclasts attach to bone, reducing their activity and the reabsorption of bone. Bisphosphonates have some important side effects: - Reflux and oesophageal erosions - Atypical fractures (e.g., atypical femoral fractures) - Osteonecrosis of the jaw (regular dental checkups are recommended before and during treatment) - Osteonecrosis of the external auditory canal Oral bisphosphonates are taken on an empty stomach with a full glass of water. Afterwards, the patient should sit upright for 30 minutes before moving or eating to reduce the risk of reflux and oesophageal erosions. Examples of bisphosphonates are: - Alendronate 70 mg once weekly (oral) - Risedronate 35 mg once weekly (oral) - Zoledronic acid 5 mg once yearly (intravenous) The NICE CKS (2023) recommend reassessing treatment with bisphosphonates after 3-5 years. They suggest a repeat DEXA scan and stopping treatment if the T-score is more than -2.5. Treatment is continued in high-risk patients. 4. Other specialist options for treating osteoporosis (where bisphosphonates are not suitable) include: - Denosumab (a monoclonal antibody that targets osteoclasts) - Romosozumab (a monoclonal antibody that targets sclerostin – a protein in osteocytes that inhibits bone formation) - Teriparatide (acts as parathyroid hormone) - Hormone replacement therapy (particularly in women with early menopause) - Raloxifene (a selective oestrogen receptor modulator): Raloxifene stimulates oestrogen receptors in the bone but not in the uterus or breast. It increases the risk of venous thromboembolism. - Strontium ranelate (a similar element to calcium that stimulates osteoblasts and blocks osteoclasts): Strontium ranelate increases the risk of venous thromboembolism and myocardial infarction.

Answer 55

Acute left ventricular failure occurs when an acute event results in the left ventricle being unable to move blood efficiently through the left side of the heart and into the systemic circulation. Cardiac output is the volume of blood ejected by the heart per minute. Stroke volume is the volume of blood ejected during each beat. Cardiac output is the product of stroke volume x heart rate. When blood cannot flow efficiently through the left side of the heart, there is a backlog of blood waiting in the left atrium, pulmonary veins and lungs. As these areas experience an increased volume and pressure of blood, they start to leak fluid and cannot reabsorb excess fluid from the surrounding tissues, resulting in pulmonary oedema. Pulmonary oedema is where the lung tissue and alveoli are filled with interstitial fluid. This interferes with normal gas exchange in the lungs, causing shortness of breath and reduced oxygen saturation.

Answer 56

Acute left ventricular failure is often the result of decompensated chronic heart failure. The potential triggers are: - Iatrogenic (e.g., aggressive IV fluids in a frail elderly patient with impaired left ventricular function) - Myocardial infarction - Arrhythmias - Sepsis - Hypertensive emergency (acute, severe increase in blood pressure)

Answer 57

Acute LVF typically presents with acute shortness of breath. This is exacerbated by lying flat and improves on sitting up. Acute LVF causes a type 1 respiratory failure (low oxygen without an increased carbon dioxide). Symptoms include: - Shortness of breath - Looking and feeling unwell - Cough with frothy white or pink sputum Signs on examination include: - Raised respiratory rate - Reduced oxygen saturations - Tachycardia (fast heart rate) - 3rd heart sound - Bilateral basal crackles (sounding “wet”) on auscultation of the lungs - Hypotension in severe cases (cardiogenic shock) There may also be signs and symptoms related to the underlying cause, for example: - Chest pain in acute coronary syndrome - Fever in sepsis - Palpitations with arrhythmias If they also have right-sided heart failure, you could find: - Raised jugular venous pressure (JVP), caused by a backlog on the right side of the heart, leading to an engorged internal jugular vein in the neck - Peripheral oedema of the ankles, legs and sacrum

Answer 58

Assessment in patients with acute left ventricular failure includes: 1. Clinical assessment (history and examination, starting with an ABCDE approach in any acutely unwell patient) 2. ECG to look for ischaemia and arrhythmias 3. Bloods for anaemia, infection, kidney function, BNP, and consider troponin if suspecting myocardial infarction 4. Arterial blood gas (ABG) 5. Chest x-ray 6. Echocardiogram

Answer 59

B-type natriuretic peptide (BNP) is a hormone released from the heart ventricles when the cardiac muscle (myocardium) is stretched beyond the normal range. A raised BNP blood result indicates the heart is overloaded beyond its normal capacity to pump effectively. The action of BNP is to relax the smooth muscle in blood vessels. This reduces systemic vascular resistance, making it easier for the heart to pump blood through the system. BNP also acts on the kidneys as a diuretic to promote water excretion in the urine. This reduces the circulating volume, helping to improve the function of the heart in someone that is fluid-overloaded. BNP is sensitive but not specific. This means that when the result is negative, it helps rule out heart failure, but it can be positive due to other causes. Other causes of a raised BNP include: - Tachycardia - Sepsis - Pulmonary embolism - Renal impairment - COPD

Answer 60

Echocardiogram Echocardiography is helpful in assessing the function of the left ventricle and any structural abnormalities in the heart. A key measure of the left ventricular function is the ejection fraction. This is the percentage of blood in the left ventricle that is squeezed out with each ventricular contraction. An ejection fraction above 50% is considered normal. Chest X-ray Findings Cardiomegaly on a chest x-ray is classified as a cardiothoracic ratio of more than 0.5. This is when the diameter of the widest part of the heart (the widest part of the cardiac silhouette) is more than half the diameter of the widest part of the lung fields. Upper lobe venous diversion may also be seen. Usually, when standing erect, the lower lobe veins contain more blood, and the upper lobe veins remain relatively small. In acute LVF, there is such a back-pressure that the upper lobe veins also fill with blood and become engorged. This is referred to as upper lobe diversion. This is visible as increased prominence and diameter of the upper lobe vessels on a chest x-ray. Fluid leaking from oedematous lung tissue causes additional x-ray findings of: - Bilateral pleural effusions - Fluid in interlobar fissures (between the lung lobes) - Fluid in the septal lines (Kerley lines)

Answer 61

Patients with acute left ventricular failure require hospital admission. Patients with severe pulmonary oedema or cardiogenic shock may require admission to the high dependency unit or intensive care unit. Get experienced seniors involved early. The “sodium” mnemonic can be used for remembering the basic management of acute LVF: S – Sit up O – Oxygen D – Diuretics I – Intravenous fluids should be stopped U – Underlying causes need to be identified and treated (e.g., myocardial infarction) M – Monitor fluid balance Sitting the patient up helps oxygenate the lungs. When lying flat, the fluid in the lungs spreads to a larger area. When upright, gravity takes it to the lung bases, leaving the middle and upper areas clear for better gas exchange. Oxygen should be given for reduced oxygen saturation (below 95%). As always, be cautious with patients who have COPD, where the target saturations may be 88-92%. An arterial blood gas can help guide oxygen therapy when in doubt. Diuretics (e.g., IV furosemide) increase the urine output of the kidneys, reducing the volume of fluid in the circulation. Reducing the circulating volume in a fluid-overloaded patient allows the heart to pump blood more effectively. Fluid balance monitoring involves monitoring the fluid intake (oral and IV), urine output, U&Es and body weight. Severe cases may require (guided by an experienced specialist): - Intravenous opiates, such as morphine, which act as vasodilators - Intravenous nitrates act as vasodilators, and may be considered in severe hypertension or acute coronary syndrome - Inotropes, such as dobutamine, to improve cardiac output - Vasopressors, such as noradrenalin, to improve blood pressure - Non‑invasive ventilation Invasive ventilation (involving intubation and sedation) Inotropes are medications that alter the contractility of the heart. Positive inotropes act to increase the contractility of the heart. This increases cardiac output (CO) and mean arterial pressure (MAP). They are used in patients with a low cardiac output, for example, due to acute heart failure, recent myocardial infarction or following heart surgery. Vasopressors are medications that cause vasoconstriction (narrowing of blood vessels). This increases the systemic vascular resistance and, consequently, mean arterial pressure (MAP). Vasopressors are commonly used by anaesthetists as a bolus dose or in ICU as an infusion to improve patient’s blood pressure and, therefore, tissue perfusion.

Answer 62

Chronic heart failure refers to the clinical features of impaired heart function, specifically the function of the left ventricle to pump blood out of the heart and around the body. Impaired left ventricular function results in a chronic backlog of blood waiting to flow into and through the left side of the heart. The left atrium, pulmonary veins and lungs experience an increased volume and pressure of blood. They start to leak fluid and cannot reabsorb excess fluid from the surrounding tissues, resulting in pulmonary oedema. The ejection fraction is the percentage of blood in the left ventricle squeezed out with each ventricular contraction. An ejection fraction above 50% is considered normal. Heart failure with reduced ejection fraction is when the ejection fraction is less than 50%. Heart failure with preserved ejection fraction is when someone has the clinical features of heart failure but an ejection fraction greater than 50%. This is the result of diastolic dysfunction, where there is an issue with the left ventricle filling with blood during diastole (the ventricle relaxing). Causes Ischaemic heart disease Valvular heart disease (commonly aortic stenosis) Hypertension Arrhythmias (commonly atrial fibrillation) Cardiomyopathy

Answer 63

The key symptoms of chronic heart failure are: Breathlessness, worsened by exertion Cough, which may produce frothy white/pink sputum Orthopnoea, which is breathlessness when lying flat, relieved by sitting or standing (ask how many pillows they use) Paroxysmal nocturnal dyspnoea (more detail below) Peripheral oedema Fatigue Signs on examination include: Tachycardia (raised heart rate) Tachypnoea (raised respiratory rate) Hypertension Murmurs on auscultation indicating valvular heart disease 3rd heart sound on auscultation Bilateral basal crackles (sounding “wet”) on auscultation of the lungs, indicating pulmonary oedema Raised jugular venous pressure (JVP), caused by a backlog on the right side of the heart, leading to an engorged internal jugular vein in the neck Peripheral oedema of the ankles, legs and sacrum

Answer 64

Paroxysmal nocturnal dyspnoea (PND) describes the experience that patients have of suddenly waking at night with a severe attack of shortness of breath, cough and wheeze. They may describe having to sit on the side of the bed or walk around the room, gasping for breath. They may feel suffocated and want to open a window to get fresh air. Symptoms improve over several minutes. There are a few proposed mechanisms to explain paroxysmal nocturnal dyspnoea. Firstly, fluid settles across a large surface area of the lungs as they lie flat to sleep, causing breathlessness. As they stand up, the fluid sinks to the lung bases, and the upper lung areas function more effectively. Secondly, during sleep, the respiratory centre in the brain becomes less responsive, so the respiratory rate and effort do not increase in response to reduced oxygen saturation like they would when awake. This allows the person to develop more significant pulmonary congestion and hypoxia before they wake up feeling very unwell. Thirdly, there is less adrenalin circulating during sleep. Less adrenalin means the myocardium is more relaxed, reducing cardiac output.

Answer 65

Establishing a diagnosis of heart failure involves: Clinical assessment (history and examination) N-terminal pro-B-type natriuretic peptide (NT‑proBNP) blood test ECG Echocardiogram Other investigations include: Bloods for anaemia, renal function, thyroid function, liver function, lipids and diabetes Chest x-ray and lung function tests to exclude lung pathology

Answer 66

The New York Heart Association (NYHA) classification system is used to grade the severity of symptoms related to heart failure. Here is a simplified summary: Class I: No limitation on activity Class II: Comfortable at rest but symptomatic with ordinary activities Class III: Comfortable at rest but symptomatic with any activity Class IV: Symptomatic at rest

Answer 67

- From 400 – 2000 ng/litre should be seen and have an echocardiogram within 6 weeks - Above 2000 ng/litre should be seen and have an echocardiogram within 2 weeks

Answer 68

The first-line medical treatment of chronic heart failure can be remembered with the “ABAL” mnemonic: A – ACE inhibitor (e.g., ramipril) titrated as high as tolerated B – Beta blocker (e.g., bisoprolol) titrated as high as tolerated A – Aldosterone antagonist when symptoms are not controlled with A and B (e.g., spironolactone or eplerenone) L – Loop diuretics (e.g., furosemide or bumetanide) An angiotensin receptor blocker (ARB) (e.g., candesartan) can be used instead of an ACE inhibitor if not tolerated. Avoid ACE inhibitors in patients with valvular heart disease until initiated by a specialist. Aldosterone antagonists are used when there is a reduced ejection fraction and symptoms are not controlled with an ACEi and beta blocker. Patients should have their U&Es closely monitored whilst taking diuretics, ACE inhibitors and aldosterone antagonists, as all three medications can cause electrolyte disturbances. It is particularly essential to closely monitor the renal function in patients taking ACE inhibitors and aldosterone antagonists. Both can cause hyperkalaemia (raised potassium), which is potentially fatal. Additional specialist treatments in patients with heart failure are: SGLT2 inhibitor (e.g., dapagliflozin) Sacubitril with valsartan (brand name Entresto) Ivabradine Hydralazine with a nitrate Digoxin

Answer 69

Surgical procedures may be used to treat underlying valvular heart disease. Implantable cardioverter defibrillators continually monitor the heart and apply a defibrillator shock to cardiovert the patient back into sinus rhythm if they identify a shockable arrhythmia. These are used in patients who previously had ventricular tachycardia or ventricular fibrillation. Cardiac resynchronisation therapy (CRT) may be used in severe heart failure, with an ejection fraction of less than 35%. CRT involves biventricular (triple chamber) pacemakers, with leads in the right atrium, right ventricle and left ventricle. The objective is to synchronise the contractions in these chambers to optimise heart function. A heart transplant may be considered in suitable patients with severe disease.

Answer 70

Urge incontinence is caused by overactivity of the detrusor muscle of the bladder. Urge incontinence is also known as overactive bladder. The typical description is of suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs. Women with urge incontinence are very conscious about always having access to a toilet, and may avoid activities or places where they may not have easy access. This can have a significant impact on their quality of life, and stop them doing work and leisure activities.

Answer 71

The pelvic floor consists of a sling of muscles that support the contents of the pelvic. There are three canals through the centre of the female pelvic floor: the urethral, vaginal and rectal canals. When the muscles of the pelvic floor are weak, the canals become lax, and the organs are poorly supported within the pelvis. Stress incontinence is due to weakness of the pelvic floor and sphincter muscles. This allows urine to leak at times of increased pressure on the bladder. The typical description of stress incontinence is urinary leakage when laughing, coughing or surprised.

Answer 72

Mixed incontinence refers to a combination of urge incontinence and stress incontinence. It is crucial to identify which of the two is having the more significant impact and address this first.

Answer 73

Overflow incontinence can occur when there is chronic urinary retention due to an obstruction to the outflow of urine. Chronic urinary retention results in an overflow of urine, and the incontinence occurs without the urge to pass urine. It can occur with anticholinergic medications, fibroids, pelvic tumours and neurological conditions such as multiple sclerosis, diabetic neuropathy and spinal cord injuries. Overflow incontinence is more common in men, and rare in women. Women with suspected overflow incontinence should be referred for urodynamic testing and specialist management.

Answer 74

Increased age Postmenopausal status Increase BMI Previous pregnancies and vaginal deliveries Pelvic organ prolapse Pelvic floor surgery Neurological conditions, such as multiple sclerosis Cognitive impairment and dementia

Answer 75

A medical history should distinguish between the types of incontinence. Try to differentiate between urinary leakage with coughing or sneezing (stress incontinence), and incontinence due to a sudden urge to pass urine with loss of control on the way to the toilet (urge incontinence). Assess for modifiable lifestyle factors that can contribute to symptoms: Caffeine consumption Alcohol consumption Medications Body mass index (BMI) Assess the severity by asking about: Frequency of urination Frequency of incontinence Nighttime urination Use of pads and changes of clothing Examination should assess the pelvic tone and examine for: Pelvic organ prolapse Atrophic vaginitis Urethral diverticulum Pelvic masses During the examination, ask the patient to cough and watch for leakage from the urethra. The strength of the pelvic muscle contractions can be assessed during a bimanual examination by asking the woman to squeeze against the examining fingers. This can be graded using the modified Oxford grading system: 0: No contraction 1: Faint contraction 2: Weak contraction 3: Moderate contraction with some resistance 4: Good contraction with resistance 5: Strong contraction, a firm squeeze and drawing inwards

Answer 76

A bladder diary should be completed, tracking fluid intake and episodes of urination and incontinence over at least three days. There should be a mix of work and leisure days. Urine dipstick testing should be performed to assess for infection, microscopic haematuria and other pathology. Post-void residual bladder volume should be measured using a bladder scan to assess for incomplete emptying. Urodynamic testing can be used to investigate patients with urge incontinence not responding to first-line medical treatments, difficulties urinating, urinary retention, previous surgery or an unclear diagnosis. It is not always required where the diagnosis is possible based on the history and examination.

Answer 77

Urodynamic tests are a way of objectively assessing the presence and severity of urinary symptoms. Patients need to stop taking any anticholinergic and bladder related medications around five days before the tests. A thin catheter is inserted into the bladder, and another into the rectum. These two catheters can measure the pressures in the bladder and rectum for comparison. The bladder is filled with liquid, and various outcome measures are taken: 1. Cystometry measures the detrusor muscle contraction and pressure 2. Uroflowmetry measures the flow rate 3. Leak point pressure is the point at which the bladder pressure results in leakage of urine. The patient is asked to cough, move or jump when the bladder is filled to various capacities. This assesses for stress incontinence. 4. Post-void residual bladder volume tests for incomplete emptying of the bladder 5. Video urodynamic testing involves filling the bladder with contrast and taking xray images as the bladder is emptied. Theses are only performed where necessary and not a routine part of urodynamic testing.

Answer 78

Management of stress incontinence involves: - Avoiding caffeine, diuretics and overfilling of the bladder - Avoid excessive or restricted fluid intake - Weight loss (if appropriate) - Supervised pelvic floor exercises for at least three months before considering surgery - Surgery - Duloxetine is an SNRI antidepressant used second line where surgery is less preferred Pelvic floor exercises are used to strengthen the muscles of the pelvic floor. They increase the tone and improve the support for the bladder and bowel. Pelvic floor exercises should be supervised by an appropriate professional, such as a specialist nurse or physiotherapist. Women should aim for at least eight contractions, three times daily. Surgical options to treat stress incontinence include: - Tension-free vaginal tape (TVT) procedures involve a mesh sling looped under the urethra and up behind the pubic symphysis to the abdominal wall. This supports the urethra, reducing stress incontinence. - Autologous sling procedures work similarly to TVT procedures but a strip of fascia from the patient’s abdominal wall is used rather than tape - Colposuspension involves stitches connecting the anterior vaginal wall and the pubic symphysis, around the urethra, pulling the vaginal wall forwards and adding support to the urethra - Intramural urethral bulking involves injections around the urethra to reduce the diameter and add support Where the stress incontinence is caused by a neurological disorder or other surgical methods have failed, specialist centres may offer an operation to create an artificial urinary sphincter. This involves a pump inserted into the labia that inflates and deflates a cuff around the urethra, allowing women to control their continence manually.

Answer 79

Management of urge incontinence and overactive bladder involves: - Bladder retraining (gradually increasing the time between voiding) for at least six weeks is first-line - Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin - Mirabegron is an alternative to anticholinergic medications - Invasive procedures where medical treatment fails Anticholinergic medications need to be used carefully, as they have anticholinergic side effects. These include dry mouth, dry eyes, urinary retention, constipation and postural hypotension. Importantly they can also lead to a cognitive decline, memory problems and worsening of dementia, which can be very problematic in older, more frail patients. Mirabegron is used as an alternative medical treatment for urge incontinence with less of an anticholinergic burden. However, it is worth noting that mirabegron is contraindicated in uncontrolled hypertension. Blood pressure needs to be monitored regularly during treatment. It works as a beta-3 agonist, stimulating the sympathetic nervous system, leading to raised blood pressure. This can lead to a hypertensive crisis and an increased risk of TIA and stroke. Invasive options for overactive bladder that has failed to respond to retraining and medical management include: - Botulinum toxin type A injection into the bladder wall - Percutaneous sacral nerve stimulation involves implanting a device in the back that stimulates the sacral nerves - Augmentation cystoplasty involves using bowel tissue to enlarge the bladder - Urinary diversion involves redirecting urinary flow to a urostomy on the abdomen

Answer 80

Malnutrition is an important consequence of and contributor to chronic disease. It is clearly a complex and multifactorial problem that can be difficult to manage but there are a number of key points to remember for the exam. NICE defines malnutrition as the following: - a Body Mass Index (BMI) of less than 18.5; or unintentional weight loss greater than 10% within the last 3-6 months; or - a BMI of less than 20 and unintentional weight loss greater than 5% within the last 3-6 months Around 10% of patients aged over 65 years are malnourished, the vast majority of those living independently, i.e. not in hospital or care/nursing homes.

Answer 81

Screening for malnutrition is mostly done using MUST (Malnutrition Universal Screen Tool). - it should be done on admission to care/nursing homes and hospital, or if there is a concern. For example an elderly, thin patient with pressure sores - it takes into account BMI, recent weight change and the presence of acute disease categorises patients into low, medium and high risk Step 1: measure height and weight to get a BMI score using chart. Scored from 0-2 where 0 is obese and healthy BMI and 2 is very low BMI. Step 2: Note percentage unplanned weight loss and give a score. 0=<5%, 1=5-10%, 2=>10% Step 3: establish acute disease effect and score eg If patient is acutely ill and there has been or is likely to be no nutritional intake for >5 days - Score 2 Step 4: Add scores from 1,2 and 3 Step 5: Use guides: - 0 is low risk so repeat screening in Hospital – weekly, Care Homes – monthly, Community – annually for special groups e.g. those >75 yrs - 1 is medium risk so observe: Document dietary intake for 3 days. If adequate – little concern and repeat screening. If inadequate – clinical concern so follow local policy, set goals, improve and increase overall nutritional intake, monitor and review care plan regularly - 2 or more is high risk so treat: Refer to dietitian, Nutritional Support Team or implement local policy. Set goals, improve and increase overall nutritional intake. Monitor and review care plan

Answer 82

- dietician support if the patient is at high-risk - a 'food-first' approach with clear instructions (e.g. 'add full-fat cream to mashed potato'), rather than just prescribing oral nutritional supplements (ONS) such as Ensure - if ONS are used they should be taken between meals, rather than instead of meals

Answer 83

Hypothermia is an unintentional reduction of core body temperature below the normal physiological limits. In initial stages, thermoreceptors in the skin and subcutaneous tissues sense the low temperature and cause a regional vasoconstriction. This causes the hypothalamus to stimulate the release of TSH and ACTH. It also stimulates heat production by promoting shivering. Definitions: Mild hypothermia: 32-35°C Moderate or severe hypothermia: < 32°C

Answer 84

Causes can include: Exposure to cold in the environment is the major cause Inadequate insulation in the operating room Cardiopulmonary bypass Newborn babies. Risk factors: General anaesthesia Substance abuse Hypothyroidism Impaired mental status Homelessness Extremes of age

Answer 85

Signs of hypothermia include: shivering cold and pale skin. Frostbite occurs when the skin and subcutaneous tissue freeze, causing damage to cells. slurred speech tachypnoea, tachycardia and hypertension (if mild) respiratory depression, bradycardia and hypothermia (if moderate) confusion/ impaired mental state Babies with hypothermia can look healthy. However, they may be limp, unusually quiet and refuse to feed. Heat loss in newborns is extremely common, hence a hat and clothing/ blankets will be applied soon after birth.

Answer 86

1. Temperature. Special low-reading rectal thermometers or thermistor probes are preferred for measuring core body temperature. The patient's temperature should be tracked over time, to check for improvement. 2. 12 lead ECG. As the core temperature approaches 32°C to 33°C, acute ST-elevation and J waves or Osborn waves may appear 3. FBC, serum electrolytes. Haemoglobin and haematocrit can be elevated (due to haemoconcentration). Platelets and WBCs are low due to sequestration in the spleen. Monitoring potassium is advised as hypothermic patients can be hypokalaemic due to a shift of potassium into the intracellular space. 4. Blood glucose. Stress hormones are increased, and the body can have more peripheral resistance to insulin. 5. Arterial blood gas 6. Coagulation factors 7. Chest X-ray

Answer 87

- Removing the patient from the cold environment and removing any wet/cold clothing, - Warming the body with blankets - Securing the airway and monitoring breathing, - If the patient is not responding well to passive warming, you may consider maintaining circulation using warm IV fluids or applying forced warm air directly to the patient's body + rapid re-warming can lead to peripheral vasodilation and shock In severe cases, be prepared to conduct CPR. IV drugs should be avoided if possible, as the patient is more likely to have a drastic response to the drug.

Answer 88

the NHS also provides advice to the public for what NOT to do when a person has hypothermia (due to the risk of cardiac arrest): Don't put the person into a hot bath. Don't massage their limbs. Don't use heating lamps. Don't give them alcohol to drink.

Answer 89

condition often seen following administration of anaesthetic agents characterised by hyperpyrexia and muscle rigidity cause by excessive release of Ca2+ from the sarcoplasmic reticulum of skeletal muscle associated with defects in a gene on chromosome 19 encoding the ryanodine receptor, which controls Ca2+ release from the sarcoplasmic reticulum susceptibility to malignant hyperthermia is inherited in an autosomal dominant fashion neuroleptic malignant syndrome may have a similar aetiology

Answer 90

dantrolene - prevents Ca2+ release from the sarcoplasmic reticulum

Answer 91

Squamous cell carcinoma is a common variant of skin cancer. Metastases are rare but may occur in 2-5% of patients. Risk factors include: excessive exposure to sunlight / psoralen UVA therapy actinic keratoses and Bowen's disease immunosuppression e.g. following renal transplant, HIV smoking long-standing leg ulcers (Marjolin's ulcer) genetic conditions e.g. xeroderma pigmentosum, oculocutaneous albinism

Answer 92

typically on sun-exposed sites such as the head and neck or dorsum of the hands and arms rapidly expanding painless, ulcerate nodules may have a cauliflower-like appearance there may be areas of bleeding

Answer 93

Surgical excision with 4mm margins if lesion <20mm in diameter. If tumour >20mm then margins should be 6mm. Mohs micrographic surgery may be used in high-risk patients and in cosmetically important sites.

Answer 94

Rhabdomyolysis involves skeletal muscle breaking down and releasing various chemicals into the blood. Muscle cells (myocytes) undergo cell death (apoptosis), releasing: - Myoglobin - Potassium - Phosphate - Creatine kinase Potassium is the most immediately dangerous breakdown product. Hyperkalaemia can cause cardiac arrhythmias and cardiac arrest. These breakdown products can cause acute kidney injury. Myoglobin, in particular, is toxic in high concentrations. Impaired renal function results in further accumulation of these substances in the blood. Other complications include compartment syndrome and disseminated intravascular coagulation.

Answer 95

Anything that causes significant damage to muscle cells can cause rhabdomyolysis. For example: 1. Prolonged immobility, particularly frail patients who fall and spend time on the floor before being found 2. Extremely rigorous exercise beyond the person’s fitness level (e.g., endurance events or CrossFit) 3. Crush injuries 4. Seizures 5. Statins

Answer 96

Muscle pain Muscle weakness Muscle swelling Reduced urine output (oliguria) Red-brown urine (myoglobinuria) Fatigue Nausea and vomiting Confusion (particularly in frail patients)

Answer 97

Creatine kinase (CK) is the crucial diagnostic blood test for rhabdomyolysis. It is normally less than around 150 U/L. In rhabdomyolysis, it can be 1,000-100,000 U/L. It typically rises in the first 12 hours, then remains elevated for 1-3 days, then gradually falls. The higher the CK, the greater the risk of kidney injury. Myoglobinuria refers to myoglobin in the urine. It gives urine a red-brown colour. A urine dipstick will be positive for blood. Urea and electrolytes (U&E) are required for acute kidney injury and hyperkalaemia. ECGs are used to assess and monitor the heart’s response to hyperkalaemia.

Answer 98

Intravenous fluids are the mainstay of treatment to correct hypovolaemia and encourage filtration of the breakdown products. Treatment of complications, particularly hyperkalaemia, is also essential. Additional options that are debatable and have associated risks include: - Intravenous sodium bicarbonate (to increase urinary pH and reduce the toxic effects of myoglobinuria) - Intravenous mannitol (to increase urine output and reduce oedema)

Conditions List Flashcards

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