Everything Flashcards
(191 cards)
1
Q
Tools to assess fragility?
A
Prisms-7 questionnaire ( >3 indicated increased risk of fragility)
Rockwood clinical fragility index
Timed get up and go test ( equal to or more than 14 seconds = frail)
2
Q
What are the PRISMA 7 questions?
A
Are you male
Are you older than 85 years old
Do you have health problems that require you to limit your activities
Do you need someone to help you on a regular basis
In general, do you have any health conditions that require you to stay at home
If you need help, can you found on someone close to you
Do you regularly use a walking stick or wheelchair to move about
3
Q
Rockwood definition of
5) mildly frail
6) moderately frail
7) severely frail
8) very severely frail
A
5) evident slowing/ need help in high IADLs ( eg finances, transport, meds)
6) need help with all outside activities and with house keeping. Problems with stairs/ bathing / minimal assistance with dressing
7) completely dependent for personal care
8) approaching end of life - bed bound
4
Q
Meaning of instrumental activities of daily living (IADLS)
A
shopping / preparing food/ house keeping / laundry / transportation / finances
- ADL = feeding/ continence/ toileting / bathing and dressing
- is assessed by social workers
5
Q
What does the timed up and go test involve (TUGT)
A
Time how long it takes a person to get up from there seat
Walk 4 metres
Turn round and walk back
Sit back down
6
Q
Depression affect x% of older patients
A
5-10
7
Q
Geriatric depression scale (GD4)
A
Are they satisfied with their life
Do you feel that your life is empty
Are you afraid that something bad is going to happen to you
Do you feel happy most of the time
Score of > 2 = depression
Others from GDS-15 include:
Have u dropped many of your usual activities/ interests?
Do you prefer to stay at home rather than go out and do things?
Feelings of worthlessness or helplessness
Energy levels?
8
Q
GPCOG - assesses cognition
A
Give name and address ( John brown, 42 west street, kensington) and ask to repeat then tell them to remember it so that they can tell you it again in a few minutes
Ask
1) date
2) draw a clock and write the number in it
3) mark 11.10
4) ask them to tel you something in the news recently
5) recall name and address ( 5 marks)
Result is out of 9 - if < 5 impaired cognition
*requires an informant for the rest of questions and whole thing is /15
9
Q
Abbreviated mental test AMT
- assesses patients for dementia
A
Age Time Address to recall 42 west street Year Where are we? Name of the place Identify 2 people DOB Year of First World War Name of present PM Count backwards from 20 Address recall
Out of 10 - score of < 8 = cognitive impairment
10
Q
When to refer patients to multifactorial falls risk assessment
A
If > 65 and
1) 1 or more falls in past 12 months
2) present for medical attention following fall
3) preform poorly on TUGT or 180o turn
If ineligibility reassess risk at least annually
11
Q
What is rhabdomyolosis?
And how to investigate it
A
Breakdown of skeletal muscle due to direct or indirect muscle injury
Check Creatinine Kinase levels
*usually happen if patient LOC And remained on floor for a long time
12
Q
Independent risk factor of Falls in elderly
A
Polypharmacy
13
Q
What could suggest fragility
A
Delirium Immobility Falls Incontinence Susceptibility of side effects from meds
14
Q
Meds that can lead to syncope
A
- Anti hypertensives especially ACE
- B blockers
- Diabetic meds (sulfonylureas/ insulin and DPP4 inhibitors e.g. sitagliptin)
- BDZ
15
Q
Screening toolkit for medication review in elderly?
A
STOPSTART
16
Q
Stop Thiazides Diuretic If patient has
A
Significant hypoNa , hypoK+ , hyperCa or with recent/concurrent gout
*these can all be precipitated by thiazides diuretic
17
Q
Deprivation of liberty safeguards (or DOLS) is important in patients
A
Dementia receiving care at home or a care home
recognised those who reduced their independence or restricting there free will
18
Q
Top risk factors for delirium
A
Constipation / dehydration Pain/ fracture Hypothermia Subdural bleed Male Surgery Fragility / dementia Polypharmacy
19
Q
Signs of sepsis
A
Signs of infection e.g fever / shivering/ muscle pain
Mental decline ( sleepy/ confused/ difficult to arouse) High resp rate/ difficult breathing
TACHYCARDIA
REDUCED URING OUTPUT
Blue, pale or blotchy skin, lips or tongue
20
Q
Rockwood definition of
5) mildly frail
6) moderately frail
7) severely frail
8) very severely frail
A
5) evident slowing/ need help in high IADLs ( eg finances, transport, meds)
6) need help with all outside activities and with house keeping. Problems with stairs/ bathing / minimal assistance with dressing
7) completely dependent for personal care
8) approaching end of life - bed bound
21
Q
Meaning of instrumental activities of daily living (IADLS)
A
shopping / preparing food/ house keeping / laundry / transportation / finances
- ADL = feeding/ continence/ toileting / bathing and dressing
- is assessed by social workers
22
Q
What does the timed up and go test involve (TUGT)
A
Time how long it takes a person to get up from there seat
Walk 4 metres
Turn round and walk back
Sit back down
23
Q
Depression affect x% of older patients
A
5-10
24
Q
Geriatric depression scale (GD4)
A
Are they satisfied with their life
Do you feel that your life is empty
Are you afraid that something bad is going to happen to you
Do you feel happy most of the time
Score of > 2 = depression
Others from GDS-15 include:
Have u dropped many of your usual activities/ interests?
Do you prefer to stay at home rather than go out and do things?
Feelings of worthlessness or helplessness
Energy levels?
25
GPCOG - assesses cognition
Give name and address ( John brown, 42 west street, kensington) and ask to repeat then tell them to remember it so that they can tell you it again in a few minutes
Ask
1) date
2) draw a clock and write the number in it
3) mark 11.10
4) ask them to tel you something in the news recently
5) recall name and address ( 5 marks)
Result is out of 9 - if < 5 impaired cognition
*requires an informant for the rest of questions and whole thing is /15
26
Abbreviated mental test AMT
* assesses patients for dementia
```
Age
Time
Address to recall 42 west street
Year
Where are we? Name of the place
Identify 2 people
DOB
Year of First World War
Name of present PM
Count backwards from 20
Address recall
```
Out of 10 - score of < 8 = cognitive impairment
27
When to refer patients to multifactorial falls risk assessment
If > 65 and
1) 1 or more falls in past 12 months
2) present for medical attention following fall
3) preform poorly on TUGT or 180o turn
If ineligibility reassess risk at least annually
28
What is rhabdomyolosis?
And how to investigate it
Breakdown of skeletal muscle due to direct or indirect muscle injury
Check Creatinine Kinase levels
*usually happen if patient LOC And remained on floor for a long time
29
Independent risk factor of Falls in elderly
Polypharmacy
30
What could suggest fragility
```
Delirium
Immobility
Falls
Incontinence
Susceptibility of side effects from meds
```
31
Meds that can lead to syncope
1. Anti hypertensives especially ACE
2. B blockers
3. Diabetic meds (sulfonylureas/ insulin and DPP4 inhibitors e.g. sitagliptin)
4. BDZ
32
Screening toolkit for medication review in elderly?
STOPPSTART (if considering deprescribing as well)
Others include: BEERS / NO TEARS / Medical appropriateness index (MAI)
33
Stop Thiazides Diuretic If patient has
Significant hypoNa , hypoK+ , hyperCa or with recent/concurrent gout
*these can all be precipitated by thiazides diuretic
34
Deprivation of liberty safeguards (or DOLS) is important in patients
Dementia receiving care at home or a care home
| recognised those who reduced their independence or restricting there free will
35
Top risk factors for delirium
```
Constipation / dehydration
Pain/ fracture
Hypothermia
Subdural bleed
Male
Surgery
Fragility / dementia
Polypharmacy
```
36
Signs of sepsis
Signs of infection e.g fever/shivering/ muscle pain
```
Mental decline ( sleepy/ confused/ difficult to arouse)
High resp rate/ difficult breathing
```
TACHYCARDIA
REDUCED URINE OUTPUT
Blue, pale or blotchy skin, lips or tongue
37
Causes of Syncope
1. Medication
2. Vasovagal (reflex)
3. Carotid sinus syndrome
4. Epilepsy
5. Situational syncope
6. Orthostatic hypotension
7. Cardiac Abnormality
38
Definition of syncope
Transient, spontaneous loss of consciousness with complete recovery
39
What type of syncope?
Prodromal symptoms e.g. sweating or feeling hot/ Nausea
Prolonged standing.
Vasovagal
40
Symptoms of epilepsy
Tongue biting, deja vu, incontinence, jerking, tonic-clonic
Usually followed by confusion after the event
41
Symptoms of carotid sinus syndrome
Blackout occurring when turning head
| Usually in men aged 50 or over
42
Symptoms of Orthostatic hypotension
Dizziness/ lightheadedness/ weakness/ tunnel vision
Worse when trying to stand up and in the morning/exercise/ after meals/ prolonged standing
Relieved by sitting/laying down
* can be caused by meds: Diuretics, alpha-blockers, levodopa and TCA
43
Symptoms suggesting cardiac abnormality causing syncope
1. No prodromal features (particularly in > 65)
2. palpitations following LOC
3. New/unexplained breathless
4. May have happened during exertion
44
Orthostatic hypotension definition
Fall in SBP of > 20mmHg (or 30 in HTN patients)
OR
Fall in DBP of > 10mmHg
within 3 minutes of standing
i.e. when blood rushes down/ pool into veins on standing
45
How to measure orthostatic hypotension
Ask pt to lie down for 5 minutes then measure bp
Help the patient stand up and measure immediately or within 1 minute
Then after 3 minutes of patient standing > measure again
46
Another way of diagnosing Orthostatic hypotension other than BP measurement
Tilt- table test
47
Management of postural hypotension
Lifestyle measures:
* Avoid triggers/prolonged bed rest & warm environments, review of meds
* Advise the elderly to stand slowly, raising head on the bed whilst sleeping (15-20 degrees)
* Increasing salt intake (expands circulating blood volume), compression socks
* Diet ( increase fluid intake and eat well)
* Physical manouvres: Leg crossing/ squatting
Pharmacological:
* Fludrocortisone (first line)
* alpha receptor agonist e.g. Midodrine (monotherapy or combined with above)
48
Investigations for Vertigo
1. Sitting and standing BP (OH)
2. Dix hallpix manouvre ( BPPV)
3. Hearing test ( Menieres/Labrynthitis)
4. MRI IAM - acoustic neuroma
5. MRI brain - MS/cerebellar mass
6. Romberg's/ Unterberger stepping test
7. Neuro exam - nystagmus (cerebellar)
8. Ear exam: discharge/perforations
49
Treatment for vertigo
1. Epney maneuver (BPPV)
2. For Labyrinthitis + vestibular neuronitis = Buccal/IM Prochlorperazine for severe N&V associated with vertigo
* if less severe short oral course of PC or antihistamine e.g. cyclizine/promethazine
3. Betahistine (vertigo, HL and tinnitus associated with menieres)
4. Vestibular physiotherapy ( if chronic)
50
Causes of vertigo
1. Middle ear infection/ effusion - red bulging/ retracted tympanic membrane
2. Trauma - temporal bone fracture/ ear surgery
3. BPPv
4. Labrynthitis/ vestibular neuronitis - can follow URTI
5. Menieres- feeling of fullness, tinnitus + HL
6. Acoustic neuroma - TT + HL (usually unilateral)
51
Analgesics ladder in Elderly
1. First try measures such as weight reduction )if obese), exercise, use of walking stick
2. Paracetamol *first line or low dose NSAID (upto 1.2g daily)
3. Full dose paracetamol + low dose NSAID
4. Can increase dose of NSAID or add opioid e.g. codeine/ tramadol
52
High risk prescribing indicators
1. > 75 years + antipsychotic
2. >75 years + NSAID with no gastroprotection
3. >65 + NSAID + ACE/ARB + diuretic
4. 65 + aspirin/clopidogrel + NSAID with no
gastroprotection
5. anticoag + NSAID with no gastrop
6. Anticoag + aspirin/clopidogrel with no gastrop
53
Definition of problematic polypharmacy
when multiple medications are
1. no longer clinically indicated/ optimized
2. Harm outweighs benefit
54
Classes of high-risk drugs in the elderly that may cause adverse effects
ACE, NSAIDS, Antiplatelets/ Anticoag, Digoxin, antipsychotic & Diuretics
55
positive risk/ benefit ratio decreases or is inverted in correlation to
VODCOFLEX
1. very old age
2. Dementia
3. Co-morbidity
4. Fraility
5. Limited life expectancy
56
x % of prescriptions are issues to 60 yr olds and over
60%
57
1/3 of > 75 year olds have at least x medication
6
58
Hospital admission increases by x % with 4-5 meds and to x % with 10
25%
| 300%
59
NO TEARS tool stands for
Need and Indication
Open questions - solicit pt opinion & concordance
Tests and monitoring
Evidence and guidelines - is there better approach
Adverse reactions
Risk reduction and prevention - identify individuals patient risk
Simplification and switches - simplify regime
60
A 45 year old man has complained of shaking of both his hands which is impacting on his work as a graphic designer
Essential tremor
61
A 52 year old woman presents with stiffness of her left hand and difficulty writing letters. She is struggling to walk and has fallen on a couple of occasions
Parkinsons (Levodopa)
62
A 72 year old man is in casualty with severe breathing difficulties. He is rousable but drowsy. He has a flapping tremor of his outstretched hands
Acute severe asthma
63
What is essential tremor and treatment options
Symmetrical Tremor with no other symptoms or cause
1. No treatment - self-help measures such as reduction of caffeine, yoga, avoid stress, sleep good
2. meds - Propanolol or primidone
3. surgery - DBS
64
Type of tremor in Parkinson's
Resting tremor e.g. pill rolling
65
First-line treatment in Parkinson's
| an when should it be reviewed
Levodopa
~ every 6 months as its affects diminishes
Adjuvant such as COMT can be used with levodopa if pt experiencing dyskinesia or motor fluctuations despite loptimum levels of levodopa
66
Causes of tremor
1. Hyperthyroidism
2. drug-induced - antipsychotics
3. Wilsons disease
4. Alcohol
5. Anxiety
6. cerebellar disorder
7. Parkinsons
67
Symptoms seen in Parkinsons
impaired smell, pain, constipation, low mood, acting out in sleep, drooling, hypomimia, dysphagia,
68
4 most common motor features seen in PD
1. Rigidity
2. Tremor
3. Postural instability
4. Slowness of movement (bradykinesia)
69
Diagnosis of PD
Throrough hx and assessment
Presence of Bradykinesia with at least one other PD motor feature
* CT scan - 1st line
* can do a DAT scan if unsure about type of parkinsons
* MRI to rule out other causes
70
Presentation of a patient with suspected multisystem atrophy
```
Young patient
Hot cross bun sign on MRI?
speech and swallow deficits
Autonomic dysfunction
+ve dat scan (like IPD, LB dementia
```
71
Main features of Progressive Supranuclear Palsy (PSP)
```
Hummingbird sign on MRI
Supranuclear paralysis of eye movement
failure to vertical eye gaze
axial rigidity
freezing gait or festinating gait
```
72
common reasons for admission for acutely worse Parkinsons (falls, stiffness, shaking, slowness) is..
Poor medication concordance
Poor medication absorption
PD medication side-effects
Inter-current illness
73
Risk factors for osteoporosis
```
Fhx
Menapause / early menapause
Long term steroid use (i.e > 3 months)
smoking
drinking heavily
inactive lifestyle
BMi < 19
others: inflamm arthiritis, coeliac
female
hx of fragility fracture
```
74
What patients do not need a DEXA scan if presenting with a fragility fracture
Those > 75 and had a fragility fracture before
75
How to take bisphosphonates
1st thing in the morning with water while sitting up and remain seated for 30m inutes
76
first line treatment for osteoporosis
Alendronate 10mg once a day/70mg once a week or risedronate
| Reviewed after 5 years
77
Management of osteopenia
Lifestyle
- calcium intake of 700 - 1200mg daily - if dietary intaka < 700 give calcium supplements (same with vit D)
- weight bearing exercise
- quit smoking + reduce alcohol
78
In postmenapausal women + men > 50 with high risk of fracture you should issue
A daily dose of 800IU cholecalciferol
79
What is polymyalgia rheumatic
chronic inflammation of the muscles (mainly neck, pelvic girdle and shoulder) causing stiffness and pain
80
Symptoms of PMR
can be an abrupt onset
severe pain and stiffness bilaterally mainly in shoulder/pelvic girdle and sometimes jaw/neck
worse in the morning - usually lasts 45 mins
difficult brushing hair
normally affecting >50
Raised ESR/CRP
(sometimes low grade fever, fatigue and loss of appetite)
81
Treatment of PMR
Prednisolone 15 mg for 3 weeks
12.5mg for 3 weeks
10 for 4-8 weeks
then reduce by 1 mg every 4-8 weeks
* can cosider bone protection due to steroid ADCAL or if high risk bisphosphonates
* manage any physical disability: refer for OT/physio
82
What is Giant cell arteritis/ temperal arteritis
When the arteries, particularly those at the side of the head (the temples), become inflamed.
* medical emergency
83
Symptoms of temperal arteritis
Prodromal include: malaise, weight loss, scalp tenderness when brushing hair, fever, temporal headache
Temporal headache which may radiate to neck
temporal arteries may be pulsating, appear swollen or dilated
Tenderness on temporals
jaw pain when eating/talkin
double vision or loss of vision in both or one eye
84
Difference between treatment of GCA and PMR
PMR can wait whereas GCA requires immediate treatment with high dose oral steroids follow by referral for urgent temporal artery biopst
85
what is pagets disease of the bone?
Bone remodelling disorder that results in abnormal bone architecture
M >F + > 50
Usually incidental finding but can present with bone pain
86
Investigation of pagets disease + management
X-ray/ ALP (can be raised or normal)
MAnagmeent: refer to endocrinlogy or rheum/ Give IV or oral Zolendronate/ pain relief e.g. NSAIds
87
Complications of pagets disease
Fractures
Osteoarthritis or osteosarcoma
Cranial nerve compression or neuro symptoms due to nerve impingement
Increased CO due to greater bone vascularity
88
Signs and symptoms of Vitamin D deficiency
Muscle aches
Tiredness, feeling unwell
Bone discomfort or pain
Diagnosed if 25 (OH) D caldiciol < 25 nmol
89
Investigating Vit D deficiency
Bone profile - hypocalciema + bone disease
Vit D levels
U + E
Malabsortption screen
90
Who gets referredto palliative care?
Anyone with a non - curative life limiting disease
91
End of life care involves support, care and treatment for those who have
< 12 months to live
Involves palliative care
92
Hospice care are for those who have
< 6 months to live
93
Advance care planning involves
discussion with patient and families about future wishes and care - Advance decision to reduce treatment (ADRT) or LPOA
Also, funeral planning
94
Clinically assisted hydration and nutrition is a form of
Medical treatment > must be in the patients best interest unless patient refuses
* Capacity must be assessed
* second opinion must be sought re: removing or stopping if patient is not going to die within hours or days or Set up best interest meeting
95
Scenario re: clinically assisted hydration/ nutrition
Ms A. 89yo - 4 yrs in nursing home. Full care
Quadraplegic from osteoporotic fracture
Previously taking diet and fluid with nurses.
Acute event 'Stroke'. Unable to swallow.
GP asks for help in making decision about CANH - what do you need to know
1. best interest meeting
2. second opinion
3. prognosis with and without
4. ADRT
5. documentation
6. Friends / family ? LPOA
96
Types of lasting power of Attorney
2 types
Health and welfare - only used if pt lacks capacity
Property and financial affairs - can be used as soon as registered even if pt has capacity
97
Charity for funeral costs
Down to earth
98
Features of patients seen in terminal stage
1. Day to day deterioration
2. Exclusion of reversible causes e.g. infection, electrolyte disturbance/ deydration/ arrythmias
3. Drowsy / bed bound
4. Peripherally cynosed or cold
5. taking little or no food
99
Indications for syringe driver
```
N&V
Severe dysphagia
unable to take oral meds
severe weakness
coma
patient perferance
bowel obstruction
```
100
Can a patient refuse CPR
Yes, if has capacity
| or if no capacity but documented in ADRT
101
Final decision regarding whether to do CPR
Lies with Dr but pt and family can be involved in the decision making process
102
If the healthcare team is as certain as it can be that a person is dying as an inevitable result of underlying disease or a catastrophic health event, and CPR would not re-start the heart and breathing for a sustained period, CPR x be attempted.
should not
103
IF a patient or those close to a patient disagree with a DNACPR decision... whats your next step be
Seek a second opinion
104
What is neutropenic sepsis
A temperature of > 38°C or > 37.5 for longer than an hour
OR
Any symptoms and/or signs of sepsis in a person ( fast RR/HR, low BP, chills/shivers, reduced UO, change in conscioisness )
With an absolute neutrophil count of 0.5 x 10^9/L or lower
105
When are patient most susceptible to neutropenic sepsos
10-14 post chemo/radio
| within 1 month of chemo ( ~4%)
106
Management of neutropenic sepsis
Initial: IV fluids, IV antibiotic, Oxygen ( >96%), Blood cultures
Serial lactate measurements via ABG, monitor urine output + fluid balance hourly
Further: contact acute oncology team (usually in cancerous pts)
107
Metastatic spinal cord compression presentation
& investigations
Unexplained worsening Severe back pain especially when laying down + nocturnal pain
Pain aggravated by straining
Neurological deficits - sensory loss , bowel/bladder dysfunction
limb weakness / recent fall
Radicular pain – radiates in distribution of nerve – ‘band like’/’tightness’
* whole spine MRI or CT (if has pacemaker) - should be done within 24 hrs of presentation
108
management of MSCC
lay flat + log roll
Dexamethasone 8mg BD PO ( + PPI) - monitor glucose levels as steroids can induce diabetes
Pain control - nsaids/opiates
* contact neurosurgeon
109
Superior vena cave obstruction is common in
Patient who have lung cancer
- carcinoma of the bronchus (75%)
- sometimes mediastinal LN)
110
Symptoms of SVCO
```
dilated chest & arm veins (non-pulsatile)
breathlessness
Headaches - visual problems
Cerebral oedema
swelling in upper body
cyanosis
```
111
Management of SVCO
initial:
1) oxygen + sit patient upright
2) dexamethasone 16 mg po IV > then once daily PP
3) low dose Morphine - reduce breathlessness
4) anxiolytics for calmness
Further: notify oncology team (? intraluminal stent/ chemo) + ? thrombolysis
112
Hemorrhage is commonly seen in 6 - 14% of advanced cancer patients - what are the common cancers
Head and neck cancer
| Gi
113
Initial management of the irreversible cause of seizures
Midazolam 20-30mg over 24hours via syringe driver and titrate
114
Definition of hypercalcemia & causes
adjusted calcium levels > 2.6 mmol/L (to be taken without a tourniquet - venous stasis can falsely cause elevated calcium levels)
mild 2.6 - 3 (usually no symptoms)
Moderate 3 to 3.4
severe > 3.4 - often associated with malignancy
1. Malignany or primary hyperparathyroidism
115
Signs and symptoms of hypercalcemia
Stones bones moans and groans
```
Left/right flank pain
fatigue/ muscle weakness
bone/ muscle pain
constipation/ kidney stones
polyuria and polydipsia
```
116
Complication of hypercalcemia
Osteonecrosis of the jaw
117
causes of hypercalcaemia
Malignancy (bone metastasis - from lung, breast/ prostate/myeloma)
Primary hyperparathyroidism
118
Initial and further treatment of hypercalcemia
1. Hydration - fluids, symptom control e.g. antiemetics, laxatives, BDZ
2. Bisphosphonates e.g. pamidronate or zolendronic acid + monitor renal function/ adjusted ca2+ levels
119
Difference between primary and secondary hyperparathyroidism in terms of Ca, PTH and phosphate
1. high calcium high PTH + normal phosphate
2. low or normal calcium, high PTH and high or normal phosphate
tertiary = high calcium , very high PTH and high phosphate
Primary hyperparathyroidism (pHPT): Hypercalcemia results from abnormally active parathyroid glands.
Secondary hyperparathyroidism (sHPT): Hypocalcemia results in reactive overproduction of PTH. - due to CKD
Tertiary hyperparathyroidism (tHPT): Hypercalcemia results from untreated sHPT, with continuously elevated PTH levels.
120
Pain assessment tools in elderly
```
Mcgill pain scale
Wong-baker faces pain scale
DisDAT
Dolo plus
PainAD (for pt with advance dementia)
```
121
What is Treatment escalation plan
A tool to document conversations around clinically indicated treatments (previously called ‘ceilings of care’) and supports decision making to help manage uncertainty and consider patients wishes
Especially important for:
Patients clinically deteriorating with uncertain recovery
Would you be surprised if they died during this admission?
Are they appropriate for a DNACPR discussion?
122
What to give for opioid toxicity
Naloxone (if low RR and abnormal sats or cyanosed = AnE)
123
Most common feature on brain MRI indicating alzheimers
Hippocampus atrophy
124
Early-onset dementia vs late-onset
Early < 65
| Late is > 65 years of age
125
Most common form of dementia
Alzheimers
126
ICD -10 diagnosis for Early-onset Alzheimers disease
< 65 age
1. rapid onset and progression
2. memory impairment + aphasia, acalculia, agraphia (difficulty communicating via writing), alexia ( inability to read) or apraxia (cant do task if told)
127
ICD -10 diagnosis for late-onset Alzheimers disease
> 65 age
1. slow onset and progression
2. memory impairment predominates intellectual
128
Tests for cognition
1. MMSE
2. GP-COG
3. MOCA
4. addennbrokes
5. AMTS
129
The second most common type of dementia
Vascular
* Stepwise deterioration
* impairment associated with area of vascular incidents
130
Lewy body presentation
Visual hallucinations
PArkinsonian disorder: Rem sleep disturbance/stiffness
Frequent falls
fluctuating attention
131
Managemen of dementia
1. AChE inhibitors e.g. Donepezil (1st line) or Rivastigmine (patch)
2. Menamintine (mod - severe Alzheimer or those who cant tolerate AChE)
3. OT for home assessment, Sleep management ( Zopiclone)/ Challenging behaviour (antipsychotics)/ Low mood (antidepressants)?
132
How to assess capacity?
is the patient able to communicate (dont forget hearing aids/sign language/ speech boards)
is the patient able to understand
can the patient retain information
can the patient weigh information - pros and cons
133
Causes of memory loss
1. alcohol
2. dementia
3. delirium caused by e.g. UTI
4. hypothyroidism
5. depression
5. B12 or folate deficiency
134
Management of vascular dementia
Treat risk factors!
135
Definition of complex patient
one you cant treat with reference to the guideline - i.e not straightforward
136
A 65 year old taxi driver with a background
of type II diabetes and hypertension had a
fall at home after he woke up in the middle
of the night to go to the toilet. He is unable
to recall what happened until his wife found
him on the floor in the bathroom
Transient LOC
? cardiac problem - no prodrome features/ suddent
investigation: echo (aortic stenosis), ECG,
Advise to stop driving
137
```
A 71 year old lady who is independent and
no known history of any medical
conditions fainted during her spinning
class. She regained consciousness within
few seconds with no other residual
symptoms. This was witnessed by others.
```
Syncope/ TLOC
* situational syncope - stop the exercise
* at risk of falls?
138
A 81 year old lady currently suffering from respiratory tract
infection. She passed out for less than a minute at home which was witnessed by her daughter.
Sepsis/infection
139
True LOC meaning
| & causes
LOC without remembering what happened
* orthostatic hypotension
* reflex syncope
* cardiac
* epilepsy if associated with tongue biting/incontinence
140
Pathophys of syncope
prolonged standing/ stress > peripheral vasodilation + Venous pooling of blood > decreased blood returning to heart > Heart contracts vigorously which stimulates receptors in the heart wall > reflex via CNS to increase stretch in the ventricular wall causing profound vasodilation and bradycardia
141
Treatment of bradycardia
Pacemaker
142
Most common acute leukemia in adults
Acute myeloid leukemia
* Fast-growing cancer of the WBC in the bone marrow
143
Risk factors of AML
1. Increasing age
2. previous chemo/radio
3. exposure to high levels of radiation
4. Blood disorder or downs syndrome
5. Smoking + exposure to benzene
144
symptoms of AML
1. Gingivitis
2. frequent nose or gum bleeds/ brusing easily
3. Fatigue/tiredness
4. unintentional weight loss
5. hepatomegaly/splenomegaly
6. Pallor
7. Thrombocytopenia causes petechiae on lower limbs
145
Diagnosis of AML
Bone marrow aspiration - need > 20% blasts in peripheral blood
146
Diagnosis of polycythemia
abnormally High haematocrit (high RBC: volume of blood) - male > 0.52 and female > 0.48
+
Hb concentration - male > 185 / female > 165 g/l
147
Definition of polycythemia & types
High concentration of RBC in blood leading to thicker blood
1. Apparent = normal RBC but reduced plasma > alcohol/smoking/ dehydration/ meds- diuretics
2. Absolute
Primary - excess RBC production in BM - common is PC vera: due mutation in JAK 2 gene
Secondary (erythropoietin dependent)- due to underlying causes e.g. hypoxia or tumours releasing erythropoietin
148
Management and treatment of PolyCythaemia
Referral depending on type either specialist for 2 cause or haematologist
treatments include
1. Venesection (removal of blood - aim for HCT <0.45)
2. low dose aspirin (75mg if not CI)- blood clot
3 drugs: Hydroxycarbamide (1st line)
149
Main cause/ RF of Chronic myeloid leukemia
| & how is it diagnoses
Abnormality in the Philadelphia Chromosome (>90%)
| BM biopsy by haematologist
150
Management of Chronic myeloid leukemia
* treat ASAP with
1st line: tyrosine kinase inhibitors - Imatinib
Other: stem cell or BM transplant
151
What is Chronic lymphocytic leukemia
& diagnosis
A condition where there are too many abnormal B lymphocytes leads to inability to fight off infection - the most common type of chronic leukemia
* diagnosed by BM biopsy
152
Management of CLL
1. Early-stage + asymptomatic
2. More advanced
1. watch and wait - monitor with regular blood test for disease progression
2. Chemo/ radio / triple therapy (Fludarabine, Cyclophosphamide + IV Rituximab)
153
Multiple Myeloma pathophysiology
When to suspect?
Malignant proliferation of B lymphocytes (plasme cells) to produce large amount of a paraprotein ( 50% IgG)
If > 60 with persistent bone/back pain or unexplained fractures
154
Signs and symptoms of MM
CRAB
1. Calcium elevates
2. Renal failure
3. Anaemia + thrombocytopenia (low platelets)
4. Bone lesion/pain
5. Other: Fatigue/ WL/ symptoms of hypercalcemia
6. symptoms of hyperviscosity: visual disturbance/ cognitive impairment/headaches
7. spinal cord compression symptoms
155
Investigation for MM
1. FBC - anaemia, neutropenia and thrombocytopenia
2. Bone profile - raised ca
3. ESR
4. Plasma viscosity
156
> 60 yo patient presents with hypercalcaemia or leukopenia + presentation consistent with possible myeloma
Arrange urgent serum electrophoresis + Bence jones protein urine assessment
If either +ve = refer to 2WW
* consider these test if a pt presents with plasma viscosity, raised ESR or incidental findings on blood test and presentation consistent with ?myeloma
157
Condition in which abnormal M protein is found within ur blood. Has no symptoms. Usually found by chance. Leaves u at risk (1%) of developing into lymphoma, MM
Monoclonal gammopathy of unknown origin
* diff between this and MM is the absence of cancer features
158
Treatment for Monoclonal gammopathy of unknown origin
None required although routine monitoring as it can progress to MM
159
Difference between lymphoma and leukemia
Lymphoma affects lymphocytes - Develop in LN and lymphatic organs
Leukemia affects WBC, RBC, and platelets and they develop in BM or bloodstream
160
Cause of non-Hodgkin lymphoma
Immunodeficiency (HIV) , immunosuppressant, EBV and H pylori (gastric MALT)
161
Difference between Hodgkin and non-Hodgkin lymphoma
Hodgkin - has Reed Sternberg cells; usually affects a single set of LN (usually supradiaphragmatic) whereas non- H affects multiple LN, lymphatic organs and is diffuse
162
treatment for Hodgkin L
Chemo, radiotherapy, Steroids or high dose chemo with SC transplant
163
Treatment of non H lymphoma
Chemo, radio, mAB targeted therapy e.g. rituximab, SC transplant or surgery
164
Myelodysplastic syndrome
Group of disorders as a result of bone marrow failure and cause pancytopenia
Symptom include anaemia, breathlessness, bleeding and frequent infections
* most common in adults aged 70-80
165
Management of Myelodysplastic syndrome
1. Injection of Erythropoietin +/- G-CSF (growth factor)
| 2. Blood transfusion/ SC transplant
166
Myelodysplastic syndrome is called pre - leukemia why?
High progression to AML
167
Characteristic of CLL on peripheral blood smear
CLL
168
Characteristic of AML on peripheral blood smear
Auer rods
169
Prostate cancer is the x most common cancer in men
2nd
170
Risk factors of prostate cancer
1. increasing age
2. Black ethnicity 1 in 4
3. Obesity
4. Smoking
171
Symptoms of prostate cancer
1. Frequent urination with nocturia
2. Dribbling
3. Feeling of inability to empty bladder
4. Weak flow
5. Pain-back, perineal or testicular
blood in urine
5. Straining during urination
6. unexplained WL, fever, night sweats, lethargy or erectile dysfunction
172
Examination + investigation for prostate cancer
1. DRE - hard, nodular prostate indicative of PC
2. urinalysis
3. blood test for PSA ( > 4nmol is abnormal)
4. Transurethral ultrasound
173
Management of Prostate cancer
* if low risk (PSA <10) = watchful waiting (frequent PSA testing) or active surveillance (serial PSA, DRE and biopsy)
* intermediate - high risk (> 10) = Radical prostatectomy, external beam radiotherapy, chemo, hormonal therapy
174
When can you get ur PSA blood test
Ejaculated/ sex or vigorous exercise e.g. cycling 48 hours before
UTI cant do it for 6 week
Biopsy in the previous 6 weeks
175
BPH on DRE will appear
Smooth and symmetrical
Symptoms will mainly include voiding problems
176
Assessment
IPSS to see how affect QOL
Bladder diary/ urinary frequency volume chart
U&E / LFT (isolated raised ALP = bone metastasis)
PSA
Urine dipstick and culture
177
Management of
1. general
2. Dribbling
1. Avoid bladder irritants: caffeine, alcohol, smoking, obesity, time u drink before bed
2. Urethral milking or Pad/urinary sheath (refer to incontinence service)
Finally =Drugs: alpha blocker (alfuzosin/ tamsulosin), 5-alpha re-educated inhibitor (finasteride)
178
Pt present with blood in urine, several occasion, going toilet often but not passing to much urine, WL, accidents, nocturia, no pain on passing
DRE: Asymmetrical, nodular enlargement ‘stony hard’
Abdominal examination is normal
Weight: 6 months ago 75kg Today it is 68kg
WHAT IS YOUR DIFFERENTIAL?
Prostate carcinoma (UTI, prostatitis)
Inv: FBC (? anaemia), U&E , PSA >3
* Refer to 2 ww
179
Types of urinary incontinence
1. Stress: on exertion, sneezing, coughing or jumping
2. Urge: accompanied or preceded by urgency
3. Mixed
4. Functional: unable to reach toilet in time due to mobility/ unfamiliar surrounding
180
Overactive bladder syndrome
Name for a group of urinary symptoms - mainly uncontrolled need, urge to urinate, frequency and nocturia. Some people may leak.
OAB that occurs with urge UI is known as 'OAB wet'.
OAB that occurs without urge UI is known as 'OAB dry'.
181
Women risk factors for incontinence
1. pregnancy and parity
2. Forceps/ vaginal delivery
3. heavy birth weight
4. hysterectomy
high BMI, C section
182
Male risk factors for incontinence
1. prostatectomy
2. LUTS
3. Infections
4. Functional impairment
5. Cognitive impairment
6. Neurological disorders
183
Management of stress incontinence in women
First line = pelvic floor exercises - must be motivated - lasts 3 months
( + conservative i.e. reduce caffeine, weight, alcohol, smoking)
second line = anti-muscarinics
third line = intermittent self catheterization or suprapubic catheter if immobile
Alternatively- refer to incontinence service for pads
184
Management of UI in women
First line: - bladder retraining, if leaking
| if cognitively impaired = timed prompted programmes
185
Management of UI in man post prostatectomy
&
if not had prostatectomy
Refer for pelvic floor exercise
* refer to specialist
186
High risk groups for faecal incontinence
```
Frail old people
Women following childbirth
Neurological/spinal disease
Severe cognitive impairment / LD
Urinary incontinence
Prolapse
Colonic resection or anal surgery
Pelvic radiotherapy
```
187
What is vertigo
Sense of world spinning - rotatory feeling
Associated symptoms include: N&V, Falls, HL/Tinnitus
Causes usually otological
188
Wat is syncope?
Short-lived LOC with full recovery of function > rapid onset ? may be prodome (pre-syncope) > tonic clonic jerks may occur in syncope (usually last 15 sec) = all due to reduction of blood flow to brain
189
signs of vertigo
Nystagmus, hallpike test or abnormal tympanic membrane (red, bulging, perforated or retracted)
190
Patient presents with problems with urine leakage over past 6 months, frequent voiding, not related to coughing or sneezing
Most app initial treatment?
Investigations
Urge incontinence - Bladder retraining
*investigations include: Bladder diary for 3 days, vaginal exam for pelvic organ prolapse, urine dipstick + culture
191
57 yo referred to urogynaecology with symptoms of urge incontinence - bladder retraining unsuccessful.
What is the next step
antimuscarinics e.g oxybutynin - reduces detrusor muscle activity (originally controlled by muscarinic cholinergic receptors)
Note: oxybutynin should not be used in the frail
