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Flashcards in Potpourri Deck (164):
1

Define Hypertension

BP >140/90

2

Define Isolated Systolic Hypertension

Systolic BP >140 & diastolic BP less than 90

3

Associated Conditions with HTN

MI
CVA
PVD
CHF
Renal failure

4

CV Disease Risks

Continuous & consistent HTN & independent of other risks
Each 20/10 mmHg rise doubles risk of CVD

5

Benefits of Lowering BP

Decreased risk of stroke, MI, & HF

6

Define Dementia

Cognitive impairment more common with HTN

7

Accurately Measuring BP

Cuff size
Correct inflation
Appropriate interval
Several readings

8

Possible Reasons for Secondary HTN

Sleep apnea
Drug-induced
Chronic kidney disease
Primary aldosteronism
Reno vascular disease
Chronic steroid therapy or Cushing's syndrome
Pheochromocytoma
Coarctation of the aorta
Thyroid or parathyroid disease

9

CVD Risk Factors

HTN
Cigarette smoking
Dyslipidemia
Obesity
Physical inactivity
DM
Microalbuminuria or GFR less than 60 mL/min
Age: 55+ for men, 65+ fro women
Family Hx of premature CVD (men less than 55 or women less than 65)

10

Target Organ Damage

Heart: LVH, angina, prior MI, prior coronary revascularization, CHF
CVA/TIA
Renal disease
PAD
Retinopathy

11

Aggressive BP Management

Weight loss
Sodium restriction
Treatment with all classes of drugs except hydrazine & minoxidil

12

Laboratory Tests for BP Issues

EKG
UA
CMP
Fasting lipid panel
H/H
TSH
Microalbumin

13

Lifestyle Modification for HTN

Weight reduction
Adopt DASH eating plan
Dietary sodium reduction
Physical activity
Moderation of alcohol consumption

14

Medication Classes for HTN with Heart Failure

Thiazides
Beta-blocker
ACEI
ARB
Aldosterone antagonists

15

Medication Classes for HTN with Status Post MI

Beta-blockers
ACEI
Aldosterone antagonists

16

Medications for HTN with High CAD Risk

Thiazides
Beta-blockers
ACEI
CCBs

17

Medications for HTN with DM

Thiazides
Beta-blockers
ACEI
ARB
CCB

18

Medications for HTN with Chronic Renal Disease

ACEI
ARB

19

Medications for HTN with Recurrent Stroke Prevention

Thiazides
ACEI

20

What medication class is good for gout, history of hyponatremia, & osteopenia/osteoporosis?

Thiazides

21

What medication class is good for RAD or 2nd/3rd degree heart block, atrial tachycardia, migraines, thyrotoxicosis, essential tremor, or in the perioperative period?

Beta-blockers

22

What medication class is useful in Raynaud's Syndrome?

CCBs

23

What medication class is useful in BPH?

Alpha blockers

24

What medication classes have a risk of pregnancy?

ACEI
ARBs

25

What medication classes are good for hyperkalemia?

Aldosterone antagonists
K-sparing diuretics

26

Define Orthostatic Hypotension

Drop in standing SBP >10 mmHg

27

When should you always check orthostatic BP?

When adjusting meds

28

Differential Diagnosis of Marked BP Elevations & Acute Target Organ Damage

Encephalopaty
TIA/CVA
Papilledema
MI or unstable angina
Pulmonary edema
Life-threatening arterial bleeding or aortic dissection
Renal failure

29

Define Hypertensive Emergency

Marked BP elevations & acute target organ damage

30

Define Hypertensive Urgency

Market BP elevation but NO acute target organ damage

31

Define Pseudohypertention

When BP readings may be falsely elevated in some elderly patients with very stiff, calcified arteries

32

Treatment of HTN Reduces Incidence of

MI
Stroke
HF

33

What should you evaluate for with HTN in the elderly?

Target organ damage
Other CV risk factors

34

What is the 3rd leading cause of death & disability in the developed world?

CVA

35

Complications of Strokes

Venous thromboembolism
MI during acute period
MI or CVA first?

36

Major Risk Factors

HTN
Smoking
Atrial fibrillation
MI
Hyperlipidemia
DM
CHF
Acute ETOH abuse
TIA with >70% occlusion of carotid arteries
OCP + smoking
Hypercoagulopathy
High RBC count & hemoglobinopathy
Age, gender, race, prior stroke, & heredity

37

2 Types of Stroke

Ischemic
Hemorrhagic

38

Define TIA

Brief episodes of focal neurological deficits lasting 2-3 minutes to at most a few hours but less than 24 hours with no residual deficits with complete functional recovery

39

TIA Warning Sign of What

Impending stroke

40

Define Completed Stroke

Acute, sustained functional neurological deficit lasting from days to permanent

41

Stroke Syndromes

Internal carotid artery (ICA) occlusion
ACA occlusion
MCA occlusion
PCA occlusion
Vertebrobasilar occlusion
Lacunar infarct
Spinal stroke

42

Anterior Circulation TIA's & Stroke

Anterior or middle cerebral artery
Amaurosis fugax (monocular blindness)
Face-hand-arm-leg contralateral hemiparesis
Aphasia/dysarthria

43

MCA Occlusion

Contralateral hemiplegia in face-arm-hand
Dominant hemisphere = aphasia
Non-dominant right hemisphere = confusion, spatial disorientation, sensory & emotional neglect

44

ACA Occlusion

Sensorimotor deficit in contralateral foot & leg
Brocas or anterior conduction aphasia in dominant hemisphere
TIA's rarely affect ACA distribution

45

Posterior Circulation TIA & Stroke

Vertigo
Diplopia/dysconjugate gaze, ocular palsy homonymous hemianopsia
Sensorimotor deficits
Dyarthria
Ataxia

46

Vertebro-Basilar Posterior Circulation Occlusion

VA-PICA syndrome
Horner's syndrome
PICA-AICA-SCA acute cerebellar infarction
BA
V-B junction
Basilar apex
PCA quadrantic or homonymmous hemianopsia
PCA thalamus involvement

47

VA-PICA Syndrome

Headache
Ataxia
N/V
Ipsilateral paralysis in tongue & swallowing
Ipsilateral face & contralateral body

48

V-B Junction

Lower extremity paraplegia or tetraplegia
Conjugate or dysconjugate gaze paralysis
Constricted pupils
Respiratory depression
Coma

49

Basilar Apex

PCA junction results in hemiplegia-diplegia
Pupillary & occulomotor paralysis
Visual field defects
Stupor
Coma

50

PCA (proximal branches) Thalamus Involvement

Memory loss
Sensorimotor hemiplegias

51

Spinal Stroke

Prolonged hypotension
Intraspinal mass lesions

52

Define Lacunar Infarct

Small, deep infarcts caused by occlusion of the small arteries that penetrate deeper brain structures

53

Types of Hemorrhagic Stroke

Subarachnoid hemorrhage
Intracerebral hemorrhage

54

Presentation of Hemorrhagic Stroke

Headache
N/V
Decreased consciousness

55

Types of Intracerebral Hemorrhage

Hypertensive atherosclerotic hemorrhage
Lobar hemorrhages
Hemorrhage from vascular malformations
Bleeding into brain tumors (uncommon)
Blood dyscrasias or anticoagulants (uncommon)
Inflammatory vasculopathies (uncommon)

56

Define Subarachnoid Hemorrhage

Rupture of an artery with bleeding onto the surface of the brain

57

Causes of Subarachnoid Hemorrhage

Aneurysm
AVM
Bleeding disorder due to anticoagulants

58

Describe Subarachnoid Hemorrhage

Worst headache ever
Radiates to face & neck
Phonophobia
Photophobia
Maximal intensity immediately after onset

59

Subarachnoid Hemorrhage Physical Signs

Nuchal rigidity
Altered mental status
Poor sign if with transient loss of consciousness (seizure, cardiac dysrhythmia)
Papilledema
May not have neurological defect

60

Define Intracerebral Hemorrhage

Rupture of an artery with bleeding into the brain parenchyma

61

#1 Cause of Intracerebral Hemorrhage

Hypertension
Amyloid angiopathy

62

Differential Diagnosis of Stroke

Focal seizures
Glaucoma
Benign vertigo or Menieres disease
Cardiac syncope or syncope from other causes
Migraine HA
Intracranial neoplasm
Subdural hematoma
Epidural hematoma
Hyperglycemia
Hypoglycemia
Postcardiac arrest ischemia
Drug overdose
Meningitis, encephalitis
Trauma
Anoxic encephalopathy
Hypertensive encephalopathy

63

Diagnosis of Stroke

ABCs
H&P
EKG, monitor, pulse oximetry
Labs: CBC, electrolyte, glucose, ABG, PT/PTT, Urine drug screen, LP
CT or MR head scan
Echo, EEG
Carotid duplex ultrasonogrpahy
MRA or angiography

64

Management of Acute Stroke

Medical management
Surgical management
Prognosis

65

Medical Management

Prevention, lifestyle modification
Early recognition with rapid transport/pre-arrival notification
ABCs, O2, IV
Rapid evaluation for TPA

66

Thrombolytics

Only for ischemic stroke if given within 3 hours of onset of signs and symptoms Class I AHA recommendation

67

Contraindications Thrombolytics

BP >185/110
AMI
Seizure
Hemorrhage
LP within 7 days
Atrial puncture at incompressible site
Surgery within 14 days
Bleeding diathesis
Within 3 months of head trauma
Hx of intracranial hemorrhage
Minor or rapidly improving stroke symptoms

68

Chronic Prophylactic Anticoagulation Indications

Acute anterior MI with mural thrombus formation
Chronic a-fib with CHF within 3 months, HTN, previous thromboembolism, LV dysfunction and/or enlarged left atrium, or chronic valvular disease
A-fib without any risk factors: ASA therapy

69

Chronic Management of Stroke

Multidisciplinary approach
Psychiatric services
PT/OT/speech-language
VNS/home health attendant
Skilled nursing facility
Social services
Family support groups

70

Perform Carotid Endarterectomy

Good general health
HTN controlled
Internal carotid stenosis 70-99%
Ipsilateral stroke or TIA within 3-6 months
Surgeon with morbidity/mortality less than 2%
Worse outcome if used to treat stroke

71

Maybe Carotid Endarterectomy

Multiple coexisting comorbid conditions
HTN poorly controlled
Internal carotid artery either completely or less less than 70% occluded
No history of ipsilateral TIA or stroke
Inexperienced surgeon

72

Define Parkinson's Disease

Idiopathic slowly progressive degenerative CNS disorder characterized by tremor, muscular rigidity, bradykinesia

73

Physiology of Parkinson's Disease

Striatal dopamine is deficient & dopaminergic neurons are lost in the substansia nigra

74

Diagnosis of Parkinson's Disease

H&P
Clinically if 2/3 cardinal features

75

Cardinal Features

Tremor
Rigidity
Bradykinesia

76

Symptoms of Parkinson's Disease

Stiffness & slowed movements
Tremor or shaking at rest
Difficulty getting out of chair or rolling in bed
Frequent falls or tripping
Difficulty walking
Memory loss
Speech changes
Small handwriting
Slowness in performing ADLs
Sialorrhea

77

Physical Findings in Parkinson's Disease

Muscle rigidity, cog wheeling type
Bradykinesia
Postural instability, stooped forward posture
Decreased arm swinging in ambulatory activity
Resting/tremor/pill-rolling tremor
Masked facies
Micrographia
Dysarthria, hypokinetic, monotonous low volume
Painful dystonia
Dementia
Depression
Akathisia inability to sit still
Seborrheic dermatitis face & scalp
Autonomic dysfunction

78

Differential Diagnosis of Parkinson's Disease

Progressive supranuclear palsy
Multisystem atrophy
Shy-drager syndrome
Olivopontocerebellar atrophy
Wilson disease
Multiple strokes
Subdural hematoma
Normal pressure hydrocephalus
Basal ganglion lesion
Hypothyroidism & hyperparathyroidism
Post encephalitis
Creutzfeldt-Jacob disease

79

Treatment of Parkinson's Disease

Carbidopa/levodopa
Dopamine
MAOIs type B
Catechol-O-methyltransferase inhibitors
Amantadine
DBS
Regular exercise

80

End of Life Issues for Parkinson's Disease

Severely impaire & immobile
At risk for aspiration
Eating may become impossible
Dementia
Discuss end-of-life care issues early
Advise patient to appoint a surrogate to make medical care decisions

81

Define Polymyalgia Rheumatica

Inflammatory condition which is characterized by severe bilateral pain & morning stiffness of the shoulder, neck, & pelvic girdle

82

Epidemiology of Polymyalgia Rheumatica

Increased incidence at higher latitudes
Women > Men (3:1)

83

Presentation of Polymyalgia Rheumatica

Bilateral, severe, persistent pain in the neck, shoulders, & pelvic girdle
Pain on active & passive movement of joints
Morning stiffness more than 1 hour & after periods of rest
Myositis
Lethargy
Weight loss
Depression
Fever
Joint effusions
+/- asymmetric peripheral arthritis, carpal tunnel syndrome, edema of hands, wrists, ankles, & feet

84

Important Differential Diagnosis of Polymyalgia Rheumatica

Systemic lupus erythematosus
Polymyositis
Bacterial endocarditis
Paraneoplastic syndromes
Amyloidosis

85

Labs for Polymyalgia Rheumatica

ESR: elevated
CRP
IL-6 levels: elevated
CBC: anemia of chronic disease
Rheumatoid & ANA: not elevated
LFTs mildly elevated

86

Associated Diseases with Polymyalgia Rheumatica

Giant cell arteritis (GCA)

87

Management of Polymyalgia Rheumatica

Document symptoms & level of disability at diagnosis
Consider giant cell arteritis
Advise to seek treatment if symptoms of GCA
Monitor response to treatment via ESR & CRP
Manage residual physical or psychosocial disability
Consider other possible diagnoses
Drug therapy: prednisone, bisphosphonates, calcium & vitamin D
Referral to physiotherapist & OT

88

Symptoms of GCA

Headache
Jaw claudications
Visual disturbances

89

Prednisone & Polymyalgia Rheumatica

Some may produce dramatic response
Some may be able to come off treatment all together except exacerbations
Some may need to be on long term low dose steroids

90

Age-Related Macular Degeneration Impacts

Ability to drive
Increased rates of falls
Ability to live independently

91

Define Age-Related Macular Degeneration

Degenerative disease of the central portion of the retina (macula)
Results in loss of central vision

92

2 Classifications of Age-Related Macular Degeneration

Dry
Wet

93

Dry Age-Related Macular Degeneration

Ischemic
Retinal epithelial cell apoptosis
Activating inflammation

94

Wet Age-Related Macular Degeneration

Balance between substances that promote or inhibit blood vessel development
Vascular endothelial growth factor (VEGF)

95

Risk Factors for Age-Related Macular Degeneration

Age
Smoking
Genetics
CVD
Diet
Cataract surgery
Heavy alcohol use
Caucasians

96

History of Age-Related Macular Degeneration

Rate of vision loss
One or both eyes involved
Loss near/far vision or both
Associated symptoms
Acute distortion of loss of central vision: may be wet

97

Ophthalmologic Evaluation of Dry Age-Related Macular Degeneration

Durban appears as bright yellow spots
Atrophy appears as areas of depigmentation
May be increased pigmentation

98

Ophthalmologic Evaluation of Wet Age-Related Macular Degeneration

Subretinal fluid and/or hemorrhage
Neovascularization: grayish-green discoloration
Often require fluorescein angiogram

99

Treatment of Dry Age-Related Macular Degeneration

None
Slow progression: vitamin C, E, beta carotene, zine & copper

100

Treatment of Wet Age-Related Macular Degeneration

VEGF inhibitors
Photocoagulation
Surgery

101

Tool for Detecting Age-Related Macular Degeneration

Amsler grid

102

Types of Glaucoma

Acute angle
Secondary
Congenital
Primary open-angle

103

Secondary Glaucoma Due to

Uveitis
Old trauma
Steroid therapy

104

What glaucoma is the most common?

Primary open-angle glaucoma

105

What is the leading cause of irreversible blindness in the world?

Glaucoma

106

Primary Open-Angle Glaucoma

Optic neuropathy: "cupping"
Peripheral visual field loss followed by central field loss
Must be screened for

107

Risk Factors for Primary Open-Angle Glaucoma

Elevated IOP
Increasing age with increase risk of blindness
African Americans 4-5 x risk
Family history

108

Screening for Primary Open-Angle Glaucoma

Specialist with special equipment
Can examine optic disc for cupping

109

Treatment of Primary Open-Angle Glaucoma

Topical & systemic medications
Laser therapy
Surgery

110

Types of Angle-Closure Glaucoma

Primary
Secondary

111

Primary Angle-Closure Glaucoma

Anatomically predisposed
No identifiable secondary cause

112

Secondary Angle-Closure Glaucoma

Responsible for closure of the anterior chamber angle
Ex: fibrovascular membrane, mass, or hemorrhage

113

Risk Factors for Angle-Closure Glaucoma

Family history
Older than 40-50
Female
Hyperopia (farsightedness)
Pseudoexfoliation
Race: Inuit & Asian populations

114

Symptoms of Pressure Rising Acutely in Angle-Closure Glaucoma

Decreased vision
Halos around lights
Headache
Severe eye pain
N/V

115

Signs of Angle-Closure Glaucoma

Conjunctival redness
Corneal edema or cloudiness
Shallow anterior chamber
Mid-dilated pupil that reacts poorly to light

116

Treatment of Angle-Closure Glaucoma

Ophthalmologic emergency
Immediate referral for further evaluation

117

What is the leading cause of blindness in the world?

Cataract

118

Risk Factors for Cataracts

Age
Smoking
Alcohol
Sunlight exposure
Metabolic syndrome
DM
Systemic corticosteroid use

119

Presentation of Cataracts

Painless, progressive process
Complain of problems with night driving, reading road signs or difficulty with fine print
Increase in nearsightedness

120

Physical Exam Findings in Cataracts

Lens opacity
Darkening of the red reflex, opacities, or obscuration of ocular funds detail

121

Treatment of Cataracts

Surgery

122

Pre-Op for Cataract Surgery

Controlled HTN
Maintain medication use

123

Complications of Cataract Surgery

Endophthalmitis
Retinal detachment

124

Common Etiologies of Presbycusis

Sensorineural
Bilateral
Beginning in the high frequency range

125

Risk Factors for Presbycusis

Lifetime exposure to noise
Genetics
Medications
Older age
DM
Cerebrovascular disease
Smoking
HTN
White

126

Presentation of Presbycusis

Complain of inability to hear/understand speech in crowded or noisy environment
Difficulty understanding consonants
Inability to hear high pitched voiced

127

Associated Symptoms of Presbycusis

Tinnitus
Hearing pulsatile noise in one ear (need MRA or MRI)

128

Differential Diagnosis of Presbycusis

Cerumen impaction
TIA
CVA

129

What can presbycusis lead to?

Isolation
Depression
Low self-esteeem

130

Hearing Amplification

Done through licensed audiologist
Do not restore hearing to normal
Need to be fit and programmed properly

131

Signs/Symptoms of Hypothyroidism

Fatigue
Cold intolerance
Weakness
Lethargy
Weight gain
Constipation
Myalgias, arthralgias
Menstrual irregularities
Hair loss
Dry, course skin
Hoarse voice
Brittle nails
Myxedema
Delayed reflexes
Slow reaction time
Bradycardia

132

Define Subclinical Hypothyroidism

Normal T4
Elevated TSH

133

Define COPD

Slow progressive irreversible airway obstruction

134

Signs of COPD Exacerbations

Increased dyspnea
Infections
Respiratory failure

135

Risk Factors for COPD

Smoking
Exposure to inhalants
Alph-1 antitrypsin
Asthma
Age
Genetics

136

Pathophysiology of COPD

Inflammation
Increased mucus
Decreased ciliary movement
Air flow obstruction

137

Pathophysiology of Chronic Bronchitis

Hypertrophy of the mucus cells
Increase in number of mucus cells
Inflammation leads to formation of more mucus

138

Why Acute Exacerbations in COPD

Infections
Environmental pollution
Unknown

139

Treatment of COPD

Oxygen
Long term inhaled glucocorticoids
SABAs (add on)
Short acting anticholinergics (add on)
Glucocorticosteroids (add on)

140

Complications of COPD

Cor pulmonale
Pneumonia
Pneumothorax
Polycythemia
Arrhythmias

141

Local Deposition Effects of Inhaled Glucocorticoids

Dyphonia
Thrush
Cough/throat irritation/reflex bronchoconstriction

142

Systemic SE of Inhaled Glucocorticoids

Consider pharmacokinetics
Osteoporosis
Adrenal suppression
Increase intra-ocular pressure/cataracts

143

Signs of Worsening COPD

Decrease in BMI
Decrease in FEV1
Increased dyspnea on exertion
Need for O2

144

End Stage COPD

Hospice
Control pain
Bedridden
Support family
Get living will from patient

145

Predisposing Conditions for Community Acquired Pneumonia

Smoking
Alcohol consumption
Pulmonary edema
Malnutrition
Administration of immunosuppressive agents
Being 65+
COPD
Previous episode of pneumonia

146

Pathogens of Community Acquired Pneumonia

H. flue
Chlamydia
Strep pneumo

147

Risk Factors for Drug Resistance

65+ years old
Antibiotic therapy within last 3-6 months
Alcoholism
Medical comorbidities
Immunosuppressive illness or therapy

148

Treatment of Uncomplicated Community Acquired Pneumonia

Azithromycin
Erythromycin
Clarithromycin

149

Treatment of Complicated Community Acquired Pneumonia (cormobidities or recent antibiotic use)

Respiratory fluoroquinolones
Amoxacillin-clavulanate (Augmentin)

150

Indications for Hospitalization of Community Acquired Pneumonia

CRB-65
Confusion
Respiratory rate: >30
BP: less than 90 systolic or 60 diastolic
Age: >65

151

Underlying Factors of Patients in Long Term Care Facilities with Pneumonia

COPD
Left heart failure
Aspiration

152

Parameters for Long Term Care Facility Residents for Treatment

Able to eat & drink
Pulse: less than 100
Respiratory rate: less than 30
BP: >90 or decrease of less than 20 from baseline
O2 sat: >92% or 90% if COPD

153

Common Causes of Pain in the Elderly

Osteoarthritis
Other joint diseases
Night time leg cramps
Claudication
Neuropathies: diabetics, herpetic, idiopathic
Cancer

154

Why is pain underrated in the elderly?

Patients underreport
Health care providers hesitant to prescribe opiates

155

WHO Guidelines for Pain Management

Mild: non-opioid +/- adjuvant
Moderate: opioid +/- adjuvant
Severe: stronger opioid +/- adjuvant

156

Medications NOT to Use for Pain Management in the Elderly

Amitriptyline
Propoxyphene

157

SE of NSAIDs in the Elderly

Renal toxicity
GI
Cardiotoxicity: worsen CHF & HTN
Interacts with aspirin & warfarin

158

First Line Treatment of Pain in the Elderly

Tylenol
Arthritis strength Tylenol

159

Treatment of Neuropathic Pain in the Elderly

Gabapentin
Lyrica
Cymbalta

160

Opioids & the Elderly

Small doses spread apart
Talk heavily about SE including constipation & confusion

161

Adjuvant Therapies for Pain Management

Exercise: PT, OT, strengthening
Physical methods: ice, heat, massage
CBT
Chiropractic therapy
Acupuncture
Relaxation & guided imagery
Biofeedback

162

Define Osteoporosis

Disease characterized by low bone mass with micro architectural disruption & skeletal fragility

163

Risk Factors for Fractures

Advanced age
Previous fracture
Long-term glucocorticoid therapy
Low body weight (less than 127 pounds)
Family history of hip fracture
Smoking
Excess alcohol intake

164

Treatment for Fractures

Surgery
Analgesics
Calcitonin
Vertebroplasty
Kyphoplasty