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My Final Year 4 Revision > ACH > Flashcards

ACH Flashcards

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1
Q

What are the aetiologies of a fall?

A

DAME:

Drugs

Ageing

Medical records

Enviroment

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2
Q

Medical causes for a fall?

A

Cateracts

Cardiac arrythmia

Neurological disease - neuropathy parkinsonism, stroke

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3
Q

What differentialsa re there for vertigo?

A

Peripheral - BBPV, Meniere’s disease, vestribular neuritis, acoustic neuroma

Central - Migraine, brainstem stroke, cerebellar stroke, MS

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4
Q

How is a lying and standing blood pressure done?

A
  • Take baseline BP after 5 mins of lying down
  • Take repeat BP at 1 and 3 min since standind up
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5
Q

What is a positive/ abnormal result for a lying-standing BP?

A

Drop of 20 systolic or 10 diastolic. Also a diastolic of <90 mmHg

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6
Q

What is a a FRAX score?

A

Predicts 10 year of absolute fracture risk

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7
Q

What is the first line treatment for osteoperosis?

A

1st line is biphosphonates with Ca/Vit D suplimentation

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8
Q

What are the contraindications to biphsophonates?

A
  • swallowing difficulties
  • Barretts oesophagus
  • Severe CKD
  • hypocalcaemia
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9
Q

What SE are there for biphosphonates?

A

Indigestion

Heart burn

Stiffness

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10
Q

What would you tell a patient about how to take their biphosphonate?

A
  • Take on empty stomach
  • Take with plenty of water
  • Remain upright for 30 mins
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11
Q

Patient has a coarse tremor which is worse on movement. Mentions that perants also have the tremor. MLD and treatment?

A

Essential tremor

Treatment with propanolol or other beta-blockers

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12
Q

An elderly patient has a tremor which is worse at rest and only on one side of body. MLD?

A

Parkinsonian tremor

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13
Q

What tremors are worse on movement?

A

Dystonic

Exagerated physiological tremor

Drug induced

Hyperthyroidism

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14
Q

What is an intention tremor and what pathology does it indicate?

A

Amplitude of tremor becomes worse when reaching end point of deliberate and visual guided movement.

Indicates cerebellar pathology

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15
Q

What signs are there fore cerebellar disease?

A

DANISH

Dysdiadochokinsia

Ataxia

Nystagmus

Intention tremor

Stuccarto/slurred dysarthria

Hypertonia/ Heel-shin test

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16
Q

What is rigidity?

A

Velocity independent hypertonia common in parkinons

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17
Q

What is spasticity?

A

Velocity dependent hypertonia mainly in anti-gravity muscles.

Common in chronic UMNL like MS

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18
Q

What is the triad for lewy body dementia?

A

Dementia

Parkinsons

Visual hallucinations

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19
Q

What drug can induce parkinsons?

A

Anti-psychotics

metoclopramide

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20
Q

What is muilti-system atrophy?

A

Parkinsons with autonomic feature - hypotension, bladder instability

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21
Q

What is athe diagnostic triad for normal pressure hydrocephalus?

A

Dementia

Gait disorder

Bladder instability

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22
Q

How is normal pressure hydrocephalus diagnosed and treated?

A

Diagnosis by LP. Treated with VP shunt

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23
Q

What scoring system is used for malnutrition?

A

MUST score

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24
Q

What is the criteria for thrombolysis in a stroke?

A
  • Symptoms of acute stroke
  • Onset within 4.5 hours
  • NIHSS scoring
  • Absence of heamorraheg on CT
  • There is an extensive exclusion criteria
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25
Q

What feature ar ethere of a total anterior circulation stroke?

A

3 of:

  • Unilateral weakness of limb or face
  • Homonymous hemianopia
  • Higher cerebral dysfunction
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26
Q

What feature are there of a partial anterior circulation stroke?

A

2 of:

  • Unilateral weakness of limb or face
  • Homonymous hemianopia
  • Higher cerebral dysfunction
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27
Q

What features are there of a posteiror ciculation stroke=?

A

1 of the following:

  • Cerebellar or brainstem syndrome
  • Loss of conscioussness
  • isolated homonymous hemianopia
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28
Q

What symptoms are thre of a lucunar stroke?

A

Any 1 of the following:

  • Unilateral waekness +/- sensory deficit
  • Pure sensory ataxia
  • Ataxic hemiparesis
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29
Q

How are patients with delirium treated?

A

Attempt to orientate patient

De-escelation techniques

Haloperidol or antipsychotic (olanzapine)

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30
Q
A
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31
Q

What is included in a comprehensive geriatric assessment

A

Medical diagnosesReview of medsSocial circumstancesAssessment of cognition and moodFunctional abilityEnvironmental assessment

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32
Q

Fried’s phenotype of frailty

A

Grip strength Activity levelsWeight lossFatigue Walking speed Frailty is associated with death, institutionalisation, adverse outcomes and falls

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33
Q

Falls history

A

Before the fall- what were they doing, what was the time of day, symptoms before the fall, why do they think they fellDuring- LOC, bite tongue, incontience, injured themselves After the fall- how did they get help, could they get up, complications such as long lie, fracture, head injury Vision, cognition, other PMH, osteoporotic risk factorsDAME! Drugs, ageing, medical conditions, environment

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34
Q

Drug causes of falls

A

PolypharmacyAnti hypertensivesSedativesOpioidsPsychotropicsGlicliazide- hypoglycaemia

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35
Q

Age related causes of falls

A

Vision changes Cognitive declineGait abnormalitiesOsteoarthritis Postural instability Sarcopenia Reduction in baroreceptor sensitivity

36
Q

Medical causes

A

Cardiac - hypotension, arrhythmiaNeuro disease eg Parkinson’s, stroke, neuropathy Cataracts

37
Q

Environmental causes of fall

A

Walking aidsInappropriate footwear Carpets Home hazards

38
Q

What is vertigo

A

Sensation of room spinning. Causes include BPPV, Menieres disease, vestibular neuritis, acoustic neuroma Central causes migraine, brain stem ischaemia, cerebellum stroke, MS

39
Q

Short spells of vertigo (up to one minute), settles spontaneously, occurs on movement of head eg in and out of bed or looking up or turning quickly

A

Diagnosis BPPVDiagnosed by Dix Hallpike manoeuvre Treat with Epley

40
Q

Patient feels lightheaded, associated with pallor, sweating, often when pt is standing

A

Pre syncopal.Suggest a cerebral hypoperfusion due to hypotension. Often postural hypotension Do lying and standing BP. Check meds

41
Q

Examine patient presenting with dizziness

A

NeuroEye sightBPCardio resp- pulse, JVP, heart sounds, peripheral oedema, chest soundsMSK- examine hands, hip exam, knee exam, ankle, gait

42
Q

Tests after a fall

A

FBCTFTs, B12HbA1cBone profile Urea and electrolytesECG- arrhythmiaCK- only if there way long lie and query rhabdomyolysisUrine dip if urinary symptoms CT brain if head injury and LOC, anti coag use or neuro deficitEcho is HF symptoms Tilt table only if syncope CXR if chest symptoms

43
Q

Assess osteoporosis risk

A

FRAX tool. Assesses ten year fracture risk.

44
Q

First line osteoporosis treatment

A

Bisphosphonates, calcium, vit D supplements Alendronic acid 70mg weekly.

45
Q

Confusion assessment tools

A

AMTS10 quick cognitive assessmentAddenbrookes - dementia toolMOCA good sensitivity but time consuming MMSE

46
Q

Things that can lead to confusion

A

Change in environmentSubdural haematoma or intracranial bleedsHip fractureConstipation!PainLow BPDehydration Previous delirium Recent surgery Poor sleepAny infection

47
Q

Tests and tools assessing confusion and delirium

A

Confusion assessment method (acute onset, fluctuating course, imattention, disorganised thoughts, altered consciousness)4AT- alterness, attention, acute, AMT4

48
Q

Things to review if patient delirious

A

FNCUEreview for sepsis- do obsFluid intake Constipation MSU ECGCXRcalcium Blood cultures if think sepsis

49
Q

How to treat delirium

A

Identify and manage underlying cause Ensure effective communication De-escalate if distressed- use familiar staff or family. Do not moveConsider short term haloperidol or olanzapine if patient is at risk or risk of hurting others Ask about alcohol intake

50
Q

Prognosis of delirium

A

Two thirds recover (1/3 quickly, 1/3 slowly)One third do not recover completely It is associated with with numerous negative outcomes- longer hospital stays, increased incidence of dementia, increased complications such as falls and pressure ulcers, increased rate of admission to long term care, more likely to die

51
Q

Prevention of delirium

A

Good lighting, clear signage, reorientation, reduce chance of dehydration and constipation, hypoxia, try to make person mobile ASAP, infection, meds review, assess pain, ensure good nutrition, heating and visual aids, try encourage good sleep

52
Q

Steps of a medication review

A

Identify objectives of drug therapyIdentify which drugs are essential Does the patient have any unnecessary drugsAre all objectives being achievedAre there any ADR or at risks ADRsDrug cost effective Is the patient taking the meds

53
Q

What are the features of Parkinsonism

A

Bradykinesia- slowness of initiating voluntary movements. Difficulty in sustaining repetitive movements Rigidity - involuntary increase in muscle tone. Present through range of movement Tremor- rhythmic involuntary movements eg pill rollingPostural instability

54
Q

Causes of parkinonism

A

Idiopathic Drug induced- cyclizine, haloperidol, prochlorperazine, metoclopramideVascular Parkinson’s - small strokes in basal ganglia

55
Q

Features of drug induced Parkinsonism

A

Usually symmetrical onset Treatment- stop or reduce meds. Liase with psych

56
Q

Features of vascular Parkinsonism

A

Extreme shuffling gait but preserved arm swing Tremor less common Approx 50% levodopa

57
Q

Features of idiopathic Parkinson’s

A

Gradual onsetUnilateral initially and one side always worseUnilateral and fine tremorHypophoniaMicrographiaFreezing gait Treatment- levodopa or dopamine agonist and physical activity and therapy

58
Q

Essential tremor

A

On action SymmetricalAlcohol improves itFHCoarse tremorJaw tremorLeg tremorNo evidence of bradykinesia or gait disturbance Non specific beta blockers eg propanolol can be effective in reducing tremor

59
Q

Scans done to determine whether essential tremor or PD

A

DAT scan can show decreased dopamine uptake Not often indicated unless trouble distinguishing between essential tremor and PD

60
Q

Tremor worse on movement

A

Essential tremorDystonic tremorExaggerated physiological tremorHyperthyroidism Dystonic tremors

61
Q

Intention tremor

A

Cerebellum disorders.

62
Q

Dementia with Lewy Bodies

A

Triad of dementia, Parkinsonism, visual hallucinations Fluctuations in alertness Shared care with psychiatry, neurology and geriatrics

63
Q

Progressive supranuclear palsy

A

Early falls, truncate rigidity, vertical gaze palsy Reduction in midbrain volume on MRIRequires early speech and language review

64
Q

Normal pressure hydrocephalus

A

Triad of dementia, gait disorder and bladder instability Diagnostic lumbar puncture and CSF removal then ventriculoperitoneal shunt

65
Q

Three steps to diagnosing Parkinson’s disease

A

1- diagnosis of a parkinsonian syndrome 2- exclusion criteria3- supporting evidence eg unilateral tenor, preofessige, persistent asymmetry, good response to levodopa If wanting second opinion, do not try levodopa as this could mask symptoms

66
Q

Treatment of Parkinson’s disease

A

Co beneldopaLevodopa with benserazide which acts as a dopa decarboylase inhviitor so stops the additional creation of dopamine outside of the brain therefore more dopamine for the brain and less systemic side effects eg nausea Second line is dopamine agonist. These are not desirable as can cause hallucinations and behavioural problems eg gambling, overeating, hyper sexuality

67
Q

What is the MUST score

A

Malnutrition universal screening toolFive step screening tool to identify adults who are malnourished, at risk of malnutrition or are obese1. Measure height and weight to get BMI2. Note percentage unplanned weight loss and score using tables3. Establish acute disease effect and score4. Add scores from steps 1- 3 to obtain risk of malnutrition 5. Use management guidelines and or local policy to develop care plan

68
Q

Grading of ulcers

A

1 non blanchable erythema. Skin intact2. Partial thickness loss- abrasion or clear blister3. Full thickness skin loss. Sub cut fat may be visible4. Muscle or bone or tendons exposed

69
Q

How to prevent pressure ulcers

A

SKINS support surface needs to be adequateKeep or movingIncontinence (manage) Nutrition and hydration Skin inspection to Detect early signs

70
Q

How to identify stroke, in community and in A&E

A

Community - FASTA&E- Rosier score

71
Q

If stroke suspected, what should you do

A

CT ASAP to look fo signs of haemorrhage. CT angiography can also help. Take full history Thrombolysis alteplase if under 4.5 hours

72
Q

Thrombolysis check list

A

Symptoms of acute strokeOnset in last 4.5 hours Measurable deficit on NIHSSAbsence of haemorrhage on scan

73
Q

Follow up after thrombolysis

A

CT scan after 24 hours to check that there has been no haemorrhage following thrombolysis Do NIHSS again to see if there is an improvement Refer to physio and OT

74
Q

Unilateral weakness of face, arm and legHomonymous hemianopiaHigher cerebral dysfunction - dysphasia

A

Total anterior circulation stroke

75
Q

Two of :unilateral weakness of face, arm legHomonymous hemianopia Higher cerebral dysfunction

A

Partial anterior circulation syndrome

76
Q

One of:Unilateral weakness of face, arm legPure sensory strokeAtaxic hemiparesis And no evidence of higher cerebral dysfunction

A

Lacunae syndrome

77
Q

One of Cerebellum or brainstem syndromesLoss of consciousnessIsolated homonymous hemianopia

A

Posterior circulation syndrome

78
Q

Risk factors for haemorrhagic stroke

A

HypertensionCerebral amyloid angiopathyAneurysms eg with poly cystic kidney diseaseCerebral arteriovenous malformationsBrain tumours

79
Q

If TIA, what tool should be used to assess stroke risk

A

ABCD2Age over 60Blood pressure >140/90Clinical features max 2 points (2 for unilateral weakness, 1 speech difficulty)Duration (2 for over 60, 1 for 10-59, 0 for less than 10)Diabetes 1Max 7 points 4 or Above is high risk of stroke

80
Q

Following TIA, what makes a stroke highly likely

A

ABCD2 score of over 4 AF Multiple TIAs

81
Q

DVLA And TIA

A

If normal driverStop driving immediately No driving for four weeksNo need to inform DVLA

82
Q

DVLA and stroke

A

No driving for four weeks and must tell DVLA. after the four weeks, need reassessing

83
Q

Differential for TIA

A

SyncopeAtypical seizureMigraineTemporal arteritis Retinal haemorrhage or detachmentHypoglycaemiaLabyrinthine disorders

84
Q

Test ps after TIA diagnosis

A

ECG to check for AFcarotid Doppler, do carotid endarterectomy is over 70% occluded leading to symptomsFBC, UE, LFT, lipids, blood glucose, BMI

85
Q

If AF present with TIA..

A

Do CHADS2VASC and HASBLED to assess clot and bleeding risk

86
Q

Headache, weakness in left side developed over 30 mins. Drowsy. FAST positive

A

Likely to be a haemorrhage. Still get CT

87
Q

Risk factors for stroke

A

a HTN, peripheral vascular disease, ischaemia heart disease, smoking, diabetes , AF, combined pill, clotting disorders, vasculitis, carotid stenosis

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