Integrative Flashcards by Amy L

List important factors in a falls history

How
LOC? - feelings before, during, after
Injuries sustained
Pain
Headache
Long lie
\+ collateral

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List risk factors for falls

Previous fall
Age >80
Female
Visual impairment
Medication (B-blockers, diuretics, opioids, insulin)
Gait disorder (PD, cerebellar, OA)
Poor footwear
Polypharmacy
Infection
Environment (loose rugs, wet floor, poor light, walking aids, cluttered home)

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Describe the examination you would undertake in someone with a fall

Temp. (infection)
MMSE/confusion screen (delirium)
Bruising
Postural BP (lying/standing)
Timed Up&amp;Go Test
Turn 180 test
ECG (heart block)
Vision test, fundoscopy
Neurological exam, cranial nerve

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Describe how to perform a lying/standing BP

Lie down for 5 mins 
Take BP
Stand up for 1 min
Take BP 
Continue standing for 3 mins
Take BP

Positive if drop in systolic BP >20mmHg/drop in diastolic BP by 10mmHg with symptoms/systolic BP <90 when standing

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List some investigations taken after a fall

Bloods - FBC, U&amp;Es, LFTs, TFTs, B12, glucose)
Urinalysis
ABG
ECG/ECHO
CT head

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List the management of falls

Referral to ED (injuries), AFU (medical cause of fall), OP falls clinic, community OT/PT, age concern
Falls assessment and bone health review - FRAX, DEXA, bisphosphonates
Medication review (e.g. NO TEARS, STOPP/START)

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Describe the NO TEARS in a medication review

Need/indication
Opinion of patient
Tests
Evidence/guideline change
ADRs/side effects
Risk reduction
Simplification/dosset box

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List red flag symptoms of stroke

Proceeded by a headache
Progressive neurology
Decreasing GCS
Falls
Systemic illness
No vascular RFs

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List important factors in a stroke history

Onset (morning?)
Progression of symptoms
Symptoms - NIH stroke scale, FAST
Associated features - raised ICP

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What examination would you perform in a patient with a stroke?

Neurological examination

NIH stroke scale

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List differentials for a stroke

SAH
Bell's palsy
Brain tumour
Brain abscess
Hemiplegic migraine

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List risk factors for a stroke

CVS RFs (smoking, hypercholesterolaemia, hyperlipidaemia)
AF
Post partum
PFO
COCP use

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What is a stroke?

Sudden onset of focal neurological deficit attributable to a vascular cause

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Describe a stroke classification system

Bamford/Oxford Stroke Classification
TACS = all three of: unilateral weakness (+/- sensory deficit) of face, arm and leg + homonymous hemianopia + higher cortical dysfunction (dysplasia, visuospatial disorder)
PACS = two out of: unilateral weakness (+/-sensory deficit) of face, arm and leg + homonymous hemianopia + higher cerebral dysfunction
POCS = one of: cranial nerve palsy and contralateral motor/sensory deficit + bilateral motor/sensory deficit + conjugate eye movement disorder + cerebellar dysfunction + isolated homonymous hemianopia
LACS = one of: pure sensory stroke + pure motor stroke + sensori-motor stroke + ataxic hemiparesis

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State the most likely cause of each different type of stroke

TACS = cardiac emboli - affects areas of brain supplies by both ACA + MCA
PACS = large vessel disease - only part of anterior circulation is compromised 
POCS = cerebellar/brainstem - posterior circulation is compromised
LACS = small vessel disease - no loss of higher cerebral functions

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Describe the blood supply of the brain

ACA - anteromedial cerebrum (frontal, medial)
MCA - lateral cerebrum (frontal, lateral, parietal, temporal)
PCA - medial and lateral posterior cerebrum (occipital)

Describe the acute assessment of a stroke

Ix - CT head, clotting, U&Es, cholesterol

Mx - O2 if sats <94%, thrombosis, HTN management

State the management of a stroke that presents in <4.5h

Thrombolysis with alteplase

Aspirin 300mg

Describe the management of an acute stroke

Aspirin 300mg OD for 14 days
Clopidogral 75mg
Consider thrombolysis
Maintain BP <130/80
Statin
Transfer to stroke unit
Advice smoking cessation

List complications of stroke

Seizures
Stroke extension
Disability +incontinence
Recurrence
Depression
Cognitive decline
Infections

Define the ABCD2 score and what is it used for

= to determine the risk of stroke in the days following a TIA
Age >60:
<60 = 0
>60 = 1
BP >140/90
<140/90 = 0
>140/90 = 1
Clinical features:
No speech disturbance or unilateral weakness = 0
Speech disturbance with no unilateral weakness = 1
Unilateral weakness = 2
Duration of symptoms
<10 mins = 0
10-59 mins = 1
>60 mins = 2
Diabetes
No diabetes = 0
Diabetes = 1
0-3 = low, 4-5 = moderate, 6-7 = high

List important lifestyle changes to tell a patient following a stroke

No driving for 1mo
Smoking cessation
No LMWH

Describe the pathophysiology of Parkinson’s Disease

Low dopamine in substantia nigra in the basal ganglia (controls movement)

What is Parkinson’s Disease?

A degenerate, progressive disease affecting the basal ganglia

List the clinical features of Parkinson's

Motor features: Bradykinesia - facial immobility, difficulty initiating movement Postural instability - festinating gait Tremor - resting, pill rolling Rigidity - cogwheel (upper)/leadpipe (lower) Non motor features: Depression Sleep disturbance - restless legs, REM Autonomic dysfunction - increased sweating, drooling, constipation Falls

Describe the classical gait of a person with Parkinson's

``` Stooping Slow to initiate walking Shortened stride Shuffling, festinating Decreased arm swing Pedestal turning ```

List investigations for Parkinson's

Clinical diagnosis Test for Wilson's if <50 CT head or DaTSCAN if pyramidal/cerebellar, ?diagnosis

List management options for Parkinson's

``` Levodopa (dopamine precursor) + carbidopa (decarboxylase inhibitor) Bromocriptine (dopamine agonist) Entacapone (COMT inhibitor) Selegilene (MAO-B inhibitor) Amantadine (antiviral) PT/OT/speech therapy SSRI ```

List ADRs for levodopa

``` Nausea Vomiting Confusion Chorea Ineffective ```

List differentials for Parkinson's (other causes of Parkinsonism) and the symptoms they cause

Multiple systems atrophy - autonomic, ataxia, falls Supranuclear palsy - balance/movement disorder, failure of vertical gaze Lewy body dementia - nocturnal wandering, visual hallucinations Drug induced parkinsonism - symmetrical, young, dopamine agonist/lithium/AED/metoclopramide Vascular - sudden onset, LL>UL, MRI diagnosis

List the types of patients at risk of malnutrition

Elderly Oncology Intentional weight loss Acute illness

List risk factors of refeeding syndrome

Very low BMI Unintentional weight loss >10-15% body weight in 3-6 months, little/no nutritional intake >5-10 days, low electrolytes prior, alcohol/drug (insulin, chemo, antacids, diuretics) abuse

What is refeeding syndrome?

Low phosphate, magnesium, potassium Thiamine deficiency Sodium and water retention

Describe the management of refeeding syndrome

``` Baseline bloods Daily bloods Regular ECG Feed slowly Reflace fluid Pabrinex --> thiamine PO Vit. B12 Multivitamins ```

What is advanced care planning?

The process of conversation to discuss possible future situations and understand patient preferences e.g. preferred place of care/death, DNACPR, ADRT, power of attorney, anticipatory medication

Describe the pathophysiology of dying

Respiratory secretions Decreased brain perfusion - drowsy, delirium Decreased cardiac function - thready pulse, cool, mottled Decreased renal perfusion - low urine output Decreased metabolic rate - low oral intake, fatigue

Describe how to verify death

Unresponsive No central pulse, heart sounds or respiratory effort for 2 mins Pupils fixed and dilated