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Senior - Geriatrics > 4 - Presentation Of Disease > Flashcards

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
Q

Sxs of hypothyroid?

A

Dry skin

Alopecia

Diminished reflexes

Cold intolerance

Decreased max HR

Arthritic complaints

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26
Q

Which is more common - multinodular goiter or Graves dz?

A

Goiter

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27
Q

What drug may cause hyperthyroidism?

A

Amiodarone

Contains iodine and may cause iodine excess

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28
Q

What is apathetic hyperthyroidism?

A

Depressed, withdrawn, unanimated appearance

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29
Q

Txt for thyroid dz?

A

Start low, go slow

Levothyroxine - initial dose 12.5 - 25mcg/day

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30
Q

Thyroid dz presentation in geri’s vs. younger persons?

A

Physical signs may be different

Classic eye findings are less common

Tremor - may be a benign finding

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31
Q

Management of hyperthyroid in geri’s?

A

Usually radioactive iodine ablation and/or antithyroid drugs

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32
Q

How will MI present in geri?

A

More likely to present WITHOUT chest pain!

Asymptomatic myocardial ischemia is more frequently found on ECG

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33
Q

If you see conduction defects on geri’s ECG, you must worry about:

A

Onset of coronary artery dz

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34
Q

MC symptom of ACS in patient’s over 80 yrs?

A

SOB

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35
Q

What may be the presenting symptom in a geriatric patient after an MI?

A

Delirium

Delirium has a super-broad differential

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36
Q

What does a geri patient presenting to acute care with vague, atypical sxs have until ruled out?

A

Coronary ischemia / infarction

Do ECG
Get enzymes

RISK FACTORS SIMILAR TO YOUNGER PATIENTS

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37
Q

Is being old a contraindication to thrombolytics in the setting of ACS?

A

Nope

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38
Q

Minimal management for ACS (if not contraindicated)

A

ASA 81mg daily
ACEI
BB
Statin

39
Q

Causes of CHF

A

Obstruction (valve dz)
Myocardial failure
Impaired filling
Volume overload

40
Q

CHF is most commonly associated with:

A

Prolonged systolic HTN

41
Q

Sxs of CHF include:

A 
SOB
DOE
Weight gain
Lower leg edema
Fatigue
S3 or S4
Coarse-wet inspiratory rales in the lower lung fields
42
Q

NYHA CHF categories

A

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
Q

Preferred test for evaluation of LV function?

A

Echocardiography

Note: cardiac cath remains “Gold Standard” although not necessarily for elderly

44
Q

Obstructive lesions of CHF may require:

A

Surgical intervention

45
Q

Therapy for systolic CHF:

A

Afterload reduction: ACEI’s

Volume overload: diuretics

Digoxin: reduces frequency of CHF exacerbations

Beta-blockers should be prescribed unless contraindicated

46
Q

What is the MC valvular disorder in the elderly?

A

Mitral regurgitation

47
Q

Txt for mitral regurg:

A

Mild - nothing

Mod-severe - ACEI’s

Acute, severe MR w/ pulmonary edema = poor prognosis

48
Q

Mitral stenosis is associated with:

A

Rheumatic fever

49
Q

Sxs of mitral stenosis include:

A

New onset a-fib or CHF sxs

50
Q

What medical prophylaxis will patients with persistent a-fib or a-fib with clot risks receive?

A

Warfarin

51
Q

Txt for aortic insufficiency?

A

Control HTN

Txt dyslipidemias

In order to:
Decrease risk of aortic root aneurysms and aortic dissection

52
Q

Is aortic stenosis common in geri’s?

A

Yup - affects 20% of people over 80yrs

53
Q

Sxs of aortic stenosis

A

Exertional angina

Dizziness / syncope

Dyspnea

54
Q

All patients with new-onset a-fib should get:

A

An echo

Also, r/o hyperthyroidism and electrolyte imbalance

55
Q

Therapy for a-fib includes

A

Rate/rhythms control and thrombolytic therapy

56
Q

Are frequent PVC’s in geri’s with NO underlying cardiac disease associate with increased mortality?

A

Nope - i guess it’s just a thing that happens as our hearts get older…. i’d still work it up, tho

57
Q

Predisposing factors for PAD:

A

Age, sex, heredity

Smoking, high cholesterol, HTN, physical inactivity, obese, DM

58
Q

The presence of PAD increased risk for:

A

Cardiac and cerebrovascular morbidity and mortality

59
Q

Sxs of PAD:

A

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
Q

How to screen for PAD?

A

ABI

61
Q

Txt of PAD:

A

Risk factor reduction

Exercise rehab

Daily ASA or clopidogrel (or cilostazol)

Percutaneous angioplasty

Surgery (bypass)

62
Q

Sxs of chronic venous insufficiency

A

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
Q

Dx of chronic venous insufficiency?

A

Clinical

Can utilize venous duplex ultrasonography, as well

64
Q

Txt for chronic venous insufficiency

A

Compression stockings

Ulcer care

Weight loss

Exercise

Good foot and nail care

Avoid prolonged sitting or standing

65
Q

Asthma

A

Under-dx’d and under-txt’d in geri’s

Why? Breathlessness often attributed to “old age”

Same therapy as in young people

66
Q

What is the one-year mortality after a COPD exacerbation in persons over 65?

A

50% (yikes)

67
Q

Txt for COPD patients with resting hypoxemia

A

O2

68
Q

Pharm therapy for COPD in geri’s?

A

Same as young people EXCEPT: AVOID THEOPHYLLINE

69
Q

Who to screen for Vitamin B-12 deficiency?

A

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
Q

Appendicitis in geri’s

A

High mortality rate

Bowel perf -> peritonitis and gangrene

Severe pain not likely unless appendix perfs

71
Q

In some cases of geriatric appendicitis, your only sxs might be:

A

Low-grade fever an generalized abdominal pain

72
Q

PUD in geri’s

A

Many cases present with bleeding and perforation

Classic evidence of perf such as sudden pain and rigidity may NOT occur

73
Q

Acute cholecystitis in geri’s?

A

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
Q

PE findings for constipation

A

Vague, diffuse abdominal discomfort

Possibly palpable stool in LLQ

No findings consistent with acute abdomen

Rectal exam - hard stool in vault, guaiac negative

75
Q

Meds that can cause constipation

A

Opioids

Antacids

CCB’s

Diuretics

Iron supplements

Anticholinergics

76
Q

Management of constipation

A

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
Q

Medication causes of acute renal failure?

A

Aminoglycosides
NSAIDs
ACEI’s

Hyperkalemia is a common complication

78
Q

By age 80, what percentage of men have BPH?

A

About 80%

79
Q

Ddx for BPH includes:

A

Cystitis
Bladder CA
Bladder stone
Prostate CA

80
Q

What tests should be performed in men with possible BPH?

A

DRE
UA
Renal function tests

81
Q

Txt for BPH

A

Alpha-1A blockers (tamsulosin, alfuzosin)

5-alpha reductase inhibitors (dutasteride, finasteride)

Surgery: TUIP, TURP, prostatectomy

82
Q

Is urinary incontinence a normal event in the aging process?

A

Nope

83
Q

Etiologies of urinary incontinence?

A

Prior pregnancy / childbirth

Pulmonary disease with cough

Obesity

UTI’s

Neurologic disorders (parkinson’s, DM)

Cognitive and functional impairments

84
Q

Subtypes of urinary incontinence:

A

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
Q

Transient urinary incontinence causes: DIAPPERS

A 
Delirium
Infection
Atrophic vaginitis / urethritis 
Pharm
Psych 
Excess fluid output (many factors)
Restricted mobility
Stool impaction
86
Q

Findings in osteoarthritis include:

A

Thinning and fissuring of articular cartilage that occurs with aging, osteophytes and joint effusion may be present

87
Q

Initial therapy for osteoarthritis includes:

A

APA (1g up to 4x daily)

May use NSAID but beware of increased risk for GI bleed

88
Q

Txt for gout

A

Indomethacin is NOT well-tolerated in the elderly

Another NSAID or prednisone are alternative therapies

89
Q

Giant cell arteritis

A

We already know this one, nothing new here. Txt with steroids.

90
Q

Actinic keratosis

A

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
Q

Txt for actinic keratosis

A

Cryotherapy

Imiquimod or fluorouracil

92
Q

Txt for basal or squamous cell CA:

A

Electrodesiccation and curettage, or excision

93
Q

Malignant melanoma

A

Incidence and mortality continue to rise in elderly

Txt options are limited, highlighting need for increased patient education and prevention

94
Q

Why couldnt the bicycle stand up on its own?

A

It was two tired

Senior - Geriatrics (9 decks)

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