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4 - Presentation Of Disease Flashcards

1
Q

What is the most important element in making a diagnosis in the geriatric patient?

A

History

May be challenging to completely obtain

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2
Q

Barriers to eliciting a helpful hx

A 
Cultural / language 
Education / life experiences
Fear of loss of autonomy
Fear of pain, financial costs
Hearing and vision difficulties
Depression and apathy
Misunderstanding the significance of sxs
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3
Q

What might a caregiver or provider overlook when seeking a cause of sxs?

A

Reversible causes (medication use)

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4
Q

Name some examples of normal physiologic changes which may mask dz presentation

A

Masked hypoglycemia

Decreased tendency to sweat

Diminished HR response in stress

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5
Q

Infection - what normal response may be blunted in geri’s?

A

Blunted or absent fever

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6
Q

Fever in infection as it relates to mortality?

A

Fever = more favorable prognosis

Normo- or hypothermic = shittier prognosis

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7
Q

Is neck stiffness a reliable sign of meningitis in geri’s?

A

No, they’re necks are usually hurting and fucked up anyway

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8
Q

Possible Features of urosepsis

A

Delirium

Hypo- or normothermia

New-onset incontinence

Low WBC count

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9
Q

Why is pneumonia frequently missed in geri’s?

A

Afebrile in many cases

May have severe infx but not actually appear ill

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10
Q

Appendicitis in geri’s

A

Very high mortality 2/2 diminished immunocompetency / atypical presentation

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11
Q

What is the major cause of death 2/2 influenza?

A

Pneumonia

90% of influenza deaths occur in people over 65

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12
Q

Uncommon complications of influenza vaccine

A

Gullain-Barre

Anaphylaxis

Local reaction

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13
Q

Amantadine

A

Influenza A only

Inexpensive

No longer recommended for prophylaxis

Frequent GI and CNS SE’s

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14
Q

Oseltamivir

A

Tamiflu

Prophylaxis OR txt

Expensive but preferred for geri’s

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15
Q

Criteria for influenza “epidemic” in nursing home

A

3 or more pts with a fever to 101*F AND flu-like sxs within three days

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16
Q

Management of NH flu epidemic

A

Isolate the sick

Encourage staff to stay home if ill

Vaccinate any susceptible patients (who should already be vaccinated, anyway)

Consider anti-viral prophylaxis

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17
Q

TB

A

You already know it

A large percentage of geri’s admitted to NH’s are anergic to TB skin testing and at risk of developing primary infx

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18
Q

Sxs of CA

A

New weight loss

Increasing fatigue

Recent change in taste

Decreased appetite

HA

AMS

Spine pain (mets)

Pathologic fx (hypercalcemia 2/2 PTH-like hormone secreted by tumor)

Anemia

Dysphagia

Hematemesis

Melena

New-onset persistent ABD pain in women and/or postmenopausal bleeding

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19
Q

2nd MCC of death WW?

A

Stroke

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20
Q

Majority of strokes are which type?

A

Ischemic

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21
Q

Consequences of stroke?

A

90% have residual effects

30% are veggies

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22
Q

What is a significant contributor to loss of ADL’s and IADL’s?

A

Vision loss

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23
Q

Who is at increased risk for glaucoma?

A

Blacks

(+) FHx

Long-term ‘roids

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24
Q

Screen for macular degeneration with:

A

Amsler grid

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25
Sxs of hypothyroid?
Dry skin Alopecia Diminished reflexes Cold intolerance Decreased max HR Arthritic complaints
26
Which is more common - multinodular goiter or Graves dz?
Goiter
27
What drug may cause hyperthyroidism?
Amiodarone Contains iodine and may cause iodine excess
28
What is apathetic hyperthyroidism?
Depressed, withdrawn, unanimated appearance
29
Txt for thyroid dz?
Start low, go slow Levothyroxine - initial dose 12.5 - 25mcg/day
30
Thyroid dz presentation in geri’s vs. younger persons?
Physical signs may be different Classic eye findings are less common Tremor - may be a benign finding
31
Management of hyperthyroid in geri’s?
Usually radioactive iodine ablation and/or antithyroid drugs
32
How will MI present in geri?
More likely to present WITHOUT chest pain! Asymptomatic myocardial ischemia is more frequently found on ECG
33
If you see conduction defects on geri’s ECG, you must worry about:
Onset of coronary artery dz
34
MC symptom of ACS in patient’s over 80 yrs?
SOB
35
What may be the presenting symptom in a geriatric patient after an MI?
Delirium Delirium has a super-broad differential
36
What does a geri patient presenting to acute care with vague, atypical sxs have until ruled out?
Coronary ischemia / infarction Do ECG Get enzymes RISK FACTORS SIMILAR TO YOUNGER PATIENTS
37
Is being old a contraindication to thrombolytics in the setting of ACS?
Nope
38
Minimal management for ACS (if not contraindicated)
ASA 81mg daily ACEI BB Statin
39
Causes of CHF
Obstruction (valve dz) Myocardial failure Impaired filling Volume overload
40
CHF is most commonly associated with:
Prolonged systolic HTN
41
Sxs of CHF include:
``` SOB DOE Weight gain Lower leg edema Fatigue S3 or S4 Coarse-wet inspiratory rales in the lower lung fields ```
42
NYHA CHF categories
I (Mild) - no limitation on physical activity II (Mild) - slight limitation of physical activity III (moderate) - marked limitation of physical activity IV (severe) - unable to carry out any physical activity without discomfort
43
Preferred test for evaluation of LV function?
Echocardiography Note: cardiac cath remains “Gold Standard” although not necessarily for elderly
44
Obstructive lesions of CHF may require:
Surgical intervention
45
Therapy for systolic CHF:
Afterload reduction: ACEI’s Volume overload: diuretics Digoxin: reduces frequency of CHF exacerbations Beta-blockers should be prescribed unless contraindicated
46
What is the MC valvular disorder in the elderly?
Mitral regurgitation
47
Txt for mitral regurg:
Mild - nothing Mod-severe - ACEI’s Acute, severe MR w/ pulmonary edema = poor prognosis
48
Mitral stenosis is associated with:
Rheumatic fever
49
Sxs of mitral stenosis include:
New onset a-fib or CHF sxs
50
What medical prophylaxis will patients with persistent a-fib or a-fib with clot risks receive?
Warfarin
51
Txt for aortic insufficiency?
Control HTN Txt dyslipidemias In order to: Decrease risk of aortic root aneurysms and aortic dissection
52
Is aortic stenosis common in geri’s?
Yup - affects 20% of people over 80yrs
53
Sxs of aortic stenosis
Exertional angina Dizziness / syncope Dyspnea
54
All patients with new-onset a-fib should get:
An echo Also, r/o hyperthyroidism and electrolyte imbalance
55
Therapy for a-fib includes
Rate/rhythms control and thrombolytic therapy
56
Are frequent PVC’s in geri’s with NO underlying cardiac disease associate with increased mortality?
Nope - i guess it’s just a thing that happens as our hearts get older.... i’d still work it up, tho
57
Predisposing factors for PAD:
Age, sex, heredity Smoking, high cholesterol, HTN, physical inactivity, obese, DM
58
The presence of PAD increased risk for:
Cardiac and cerebrovascular morbidity and mortality
59
Sxs of PAD:
Claudication Non-healing lower extremity ulcers or gangrene - Most or caused by microtrauma - presence of PAD increases risk of pressure ulcers Skin cool to touch, dry, shiny, alopecia Diminished or absent pedal pulses
60
How to screen for PAD?
ABI
61
Txt of PAD:
Risk factor reduction Exercise rehab Daily ASA or clopidogrel (or cilostazol) Percutaneous angioplasty Surgery (bypass)
62
Sxs of chronic venous insufficiency
Edema, usually around the ankle and sparing the dorsum of the foot Ache, heaviness, or tightness of the lower extremities Varicosities Skin warm, dry, bluish-red hue Painless stasis ulcers
63
Dx of chronic venous insufficiency?
Clinical Can utilize venous duplex ultrasonography, as well
64
Txt for chronic venous insufficiency
Compression stockings Ulcer care Weight loss Exercise Good foot and nail care Avoid prolonged sitting or standing
65
Asthma
Under-dx’d and under-txt’d in geri’s Why? Breathlessness often attributed to “old age” Same therapy as in young people
66
What is the one-year mortality after a COPD exacerbation in persons over 65?
50% (yikes)
67
Txt for COPD patients with resting hypoxemia
O2
68
Pharm therapy for COPD in geri’s?
Same as young people EXCEPT: AVOID THEOPHYLLINE
69
Who to screen for Vitamin B-12 deficiency?
Any older adult who is frail, has characteristic changes in RBC and WBC with or without anemia, peripheral neuropathy, gait disorder, or unexplained neuropsychiatric sxs
70
Appendicitis in geri’s
High mortality rate Bowel perf -> peritonitis and gangrene Severe pain not likely unless appendix perfs
71
In some cases of geriatric appendicitis, your only sxs might be:
Low-grade fever an generalized abdominal pain
72
PUD in geri’s
Many cases present with bleeding and perforation Classic evidence of perf such as sudden pain and rigidity may NOT occur
73
Acute cholecystitis in geri’s?
Half of them won’t have abdominal tenderness and peritoneal inflammation They’ll often be afebrile with normal WBC’s, even with acute cholecystitis Then at surgery, they’ll discover gangrene and per
74
PE findings for constipation
Vague, diffuse abdominal discomfort Possibly palpable stool in LLQ No findings consistent with acute abdomen Rectal exam - hard stool in vault, guaiac negative
75
Meds that can cause constipation
Opioids Antacids CCB’s Diuretics Iron supplements Anticholinergics
76
Management of constipation
Hydrate Exercise Take advantage of “morning gastrocolic reflex” Increase dietary fiber Stool softeners: colace Laxatives: lactulose or sorbitol Titrate to achieve a BM every day or every other day Disimpaction / enemas may be required initially
77
Medication causes of acute renal failure?
Aminoglycosides NSAIDs ACEI’s Hyperkalemia is a common complication
78
By age 80, what percentage of men have BPH?
About 80%
79
Ddx for BPH includes:
Cystitis Bladder CA Bladder stone Prostate CA
80
What tests should be performed in men with possible BPH?
DRE UA Renal function tests
81
Txt for BPH
Alpha-1A blockers (tamsulosin, alfuzosin) 5-alpha reductase inhibitors (dutasteride, finasteride) Surgery: TUIP, TURP, prostatectomy
82
Is urinary incontinence a normal event in the aging process?
Nope
83
Etiologies of urinary incontinence?
Prior pregnancy / childbirth Pulmonary disease with cough Obesity UTI’s Neurologic disorders (parkinson’s, DM) Cognitive and functional impairments
84
Subtypes of urinary incontinence:
Total - pt loses urine in all positions at all times - could be associated with fistulas Stress - increased abdominal pressure, pelvic floor laxity Urge - overactive bladder Overflow - 2/2 chronic retention (i.e. BPH or urethral strictures)
85
Transient urinary incontinence causes: DIAPPERS
``` Delirium Infection Atrophic vaginitis / urethritis Pharm Psych Excess fluid output (many factors) Restricted mobility Stool impaction ```
86
Findings in osteoarthritis include:
Thinning and fissuring of articular cartilage that occurs with aging, osteophytes and joint effusion may be present
87
Initial therapy for osteoarthritis includes:
APA (1g up to 4x daily) May use NSAID but beware of increased risk for GI bleed
88
Txt for gout
Indomethacin is NOT well-tolerated in the elderly Another NSAID or prednisone are alternative therapies
89
Giant cell arteritis
We already know this one, nothing new here. Txt with steroids.
90
Actinic keratosis
Precursor to squamous cell CA (SCC) Face, lips, ears, forearms, dorsal aspect of the hands, lesions are scaly, rough, and adherent 2/2 excess sun exposure
91
Txt for actinic keratosis
Cryotherapy Imiquimod or fluorouracil
92
Txt for basal or squamous cell CA:
Electrodesiccation and curettage, or excision
93
Malignant melanoma
Incidence and mortality continue to rise in elderly Txt options are limited, highlighting need for increased patient education and prevention
94
Why couldnt the bicycle stand up on its own?
It was two tired

Senior - Geriatrics (9 decks)

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