Diagnosis and Investigations

Question 1

What are the causes of falls?

Answer 1

DAME -
Drugs: Polypharmacy, anti-hypertensives, oral hypoglycemics, anticholinesterase inhibitors, opiates, sedatives
Ageing: Vision changes, Osteoarthritis, Cognitive decline, Gait abnormalities
Medical: Arrhythmias/heart problems, seizure, cataracts, hypotension, stroke, neuropathy, PD
Environmental: Home hazards, shoes, walking aids

Question 2

What is vertigo?

Answer 2

A feeling of the room spinning around you

Suggests the problem is in the ear or brain

Question 3

Differential diagnosis for vertigo?

Answer 3

Meniere's Disease
Labyrinthitis
BPPV
Vestibular Schwannoma
Vestibular Neuronitis
Migraine
MS
Cerebellar Problem

Question 4

What is BPPV?

Answer 4

Short spells lasting up to 2 mins of vertigo
Recur many times throughout the day
Triggers include head movements
Diagnosed using the Dix-Hallpike manouevre

Question 5

Differential Diagnosis for dizziness?

Answer 5

Vertigo - see ddx vertigo
Presyncope
Unsteady
Psychogenic

Question 6

What symptoms would someone having presyncope experience?

Answer 6

Light-headedness
Clammy/hot
Pale
Blurred vision

Question 7

In general what does a patient mean when they say they are unsteady?

Answer 7

A general feeling of unsteadiness coming from the patients’ legs

Question 8

Why would a patient experience psychogenic dizziness?

Answer 8

Fear of falling
Loss of confidence
Panic attacks or anxiety

Question 9

Investigations of someone who is falling?

Answer 9

FBC, U&E, Bone Profile
ECG
TFT, B12, Folate

Question 10

What are the risk factors for delirium?

Answer 10

Pain
Dementia
Hip fracture
Immobility
Dehydration or constipation
Polypharmacy
Unfamiliar environment
Hypoxia
Infection
Sleep disturbance
Lack of visual or hearing aids

Question 11

What are the features of an essential tremor?

Answer 11

Bilateral
Familial
Worse on movement
Jaw tremor

Question 12

Differential diagnosis for Parkinsonism?

Answer 12

Idiopathic PD
Lewy Body Dementia
Vascular Parkinsonism
Multi System Atrophy
Drug Induced Parkinsonism
Normal Pressure Hydrocephalus
Progressive Supranuclear Palsy
Corticobasal Degneration

Question 13

What is the key feature of idiopathic PD?

Answer 13

Asymmetry of clinical features

Question 14

What is the key feature of lewy body dementia?

Answer 14

Marked cognitive impairment - presenting first
Visual hallucinations
Parkinsonism

Question 15

What is the key feature of vascular Parkinsonism?

Answer 15

Vascular risk factors i.e. smoking, high blood pressure, high cholesterol
Predominant lower body signs

Question 16

What is the key feature of drug induced Parkinsonism?

Answer 16

History of anti-psychotic drugs or other anti-dopaminergic drugs i.e. Prochlorperazine

Question 17

What is the key feature of Multi System Atrophy?

Answer 17

Autonomic dysfunction i.e. labile BP, bladder instability

Question 18

What is the key feature of Normal pressure hydrocephalus?

Answer 18

Dementia
Gait disturbance
Bladder instability

Question 19

What is the key feature of PSP?

Answer 19

Vertical gaze restriction
Early falls
Truncal rigidity

Question 20

What is the key feature of corticobasal degeneration?

Answer 20

Asymmetrical Parkinsonism and dyspraxia

Question 21

What is the average age of onset for IPD?

Answer 21

60

Question 22

What are the risk factors for developing pressure sores?

Answer 22

Prolonged periods of immobility
Nutritional deficiencies
Loss of sensation
A previous or current pressure sore
Inability to reposition yourself
Cognitive impairment

Question 23

What are the categories of elder abuse?

Answer 23

Psychological
Physical
Neglect
Sexual
Financial
Discriminatory

Question 24

What are the risk factors for elder abuse?

Answer 24

Patient: Has cognitive impairment, has a number of health needs, shared living and low income
Abuser: Caregiver burden, drug and alcohol dependency, psychiatric illness
Relationship factors: Disharmony in the relationship between the patient and the abuser, conflicted relationships
Environmental factors: Shared living, low social support

Question 25

What are the areas in which someone is assessed in a Nursing Needs Assessment?

Answer 25

``` Mobility Skin integrity Continence Nutrition Behaviour Cognition Psychological/Emotional Communication Breathing Medications Altered states of consciousness ```

Question 26

How do you prevent pressure ulcers?

Answer 26

``` Support surface is adequate Skin inspection for early signs Keep moving and mobilising Incontinence Nutrition and hydration ```

Question 27

What is involved in the NIHSS scale?

Answer 27

``` Dysarthria Alertness Patient knows own age and current month Patient can open and close eyes on command Best gaze Facial paresis Motor upper limb, L and R side Motor lower limb, L and R side Limb ataxia Visual field defect Sensory by pinprick Language Inattention ```

Question 28

What are the mimics of a TIA?

Answer 28

``` Hypoglycaemia Atypical seizure Syncope Retinal tear or detachment Migraine Temporal Arteritis Labyrinthine disorders i.e. vertigo ```

Question 29

What tests should be done to investigate someone with a suspected TIA?

Answer 29

``` Blood tests including FBC, U&E and lipids ECG Height and weight (BMI) Carotid artery USS doppler BM ```

Question 30

What is the tool used to assess immediate risk of stroke?

Answer 30

ABCD2 score The higher the score the more likely a stroke or TIA in the next 48 hours Indicates how quickly someone needs to be seen in TIA clinic

Question 31

What clinical signs point more towards a haemorrhagic stroke as opposed to an ischaemic stroke?

Answer 31

Evolution of symptoms but still over a relatively quick period of time (i.e. ~30 mins) rather than an ischaemic stroke which by definition comes on extremely quickly and is maximal at onset

Question 32

What is the main cause of a TIA?

Answer 32

Thrombus i.e. from AF or from atherosclerosis in the carotids