ACM Flashcards
Falls | Risk Factors
‘DAME’
Drugs; antiHTN, sedatives, psychotropics, polypharmacy
Ageing; sarcopenia, postural instability, baroreceptor hypersensitivity, AMD/presbyopia
Medical; hypotension, arrhythmias, peripheral neuropathy, arthritis, visual impairment, PD, cerebrovascular disease, cognitive impairment, incontinence
Environmental; home hazards, footwear, walking aids, glasses
Falls | Management
NICE guidelines:
Strength and balance training
Home hazards assessment/intervention
Vision assessment and referral
Medication review with modification/withdrawal
Osteoporosis | Diagnosis & Management
Osteopenia vs. osteoporosis
Non-pharmacological
Pharmacological
Osteopenia; BMD SD -1 to -2.5
Osteoporosis; BMD SD < -2.5
DEXA scan; to assess BMD
Marked osteopenia on plain Xray
Previous fragility fracture; wrist, hip, vertebral/spinal
RFs osteoporosis
FRAX tool to predict #risk
[Non-pharmacological] Dietary calcium intake Appropriate Vitamin D sun exposure Regular weight-bearing exercise Smoking cessation Reduce alcohol consumption
[Pharmacological]
Calcium + Vit D supplements; adcal D3
Bisphosphonates; alendronic acid
Take with plenty of water whilst sitting/standing on an empty stomach, 30mins before breakfast, remain upright for 30mins
Delirium | Causes
PINCHME + Trauma
Pain, infection, nutrition, constipation, hydration, metabolic/medication, environment
Vascular; stroke, MI, hypoxia, heart failure
Trauma; ↑ICP, SDH, SOL, #hip/pelvis
Metabolic; urinary retention, uraemia, hyponatraemia, hypercalcaemia
Drugs; anticonvulsants, sedatives, alcohol/drug withdrawal
Endocrine; thyroid, hyperglycaemia, thiamine deficiency, cachexia
Delirium | Diagnostic Criteria
4AT:
- Alertness 0/4; alert, mild sleepiness, drowsy
- AMT4 0/1/2; age, DOB, location, current year
- Inattention 0/1/2; months in reverse
- Acute change/fluctuating course 0/4; alertness, cognition, mental function in last 2wks/24hrs
Score 4+: possible delirium +/- cognitive impairment
Score 1-3: possible cognitive impairment
Score 0: delirium/cognitive impairment unlikely
Delirium | Management
Non-pharmacological
Pharmacological
Correct underlying cause
Environmental; reorientation, prevention, avoid overstimulation, avoid sensory deprivation, encourage self-care, involve family/friends, de-escalation techniques
Pharmacological; lorazepam, haloperidol (contr. in PD)
Prevent complications; falls, pressure sores, HAI, immobility/frailty
Parkinson’s disease | Clinical features
Motor
Non-motor
Asymmetrical initially
[Motor]
Bradykinesia, hypokinesia, rigidity, resting tremor, postural instability
[Non-motor] Reduced sense of smell Dribbling of saliva, dysphagia, speech Constipation Urinary frequency/urgency Sleep disturbance Visual hallucinations Depression, fatigue Cognitive impairment Dementia, memory problems
Parkinson’s disease | Management
Non-pharmacological
Pharmacological
Surgical
[Non-pharmacological]
Physio/OT
SALT
Dietician
[Pharmacological]
Medication is the main method of treatment
Drug treatment aims to increase the level of dopamine that reaches the brain to control symptoms
Drug treatment is specific to you because every person experiences Parkinson’s differently
Symptoms of Parkinson’s changes over time so medication may have to change too
Dopamine precursor; levodopa
+ peripheral decarboxylase inhibitor; carbidopa
= co-careldopa ‘SINEMET’
Dopamine agonist; pramipexole, ropinirole
+ MAOBi; selegiline, rasagiline
Surgical; DBS
Stroke | Bamford Classification
TACS
PACS
PoCS
LaCS
ACA
MCA
PCA
Haemorrhagic
TACS: 3/3 unilateral weakness + homonymous hemianopia + higher cerebral dysfunction
PACS: 2/3
PoCS: 1/3 cerebellar/brainstem ‘locked-in’ syndrome, LOC, isolated homonymous hemianopia
LaCS: 1/3 pure motor stroke, pure sensory stroke, mixed, ataxic hemiparesis
ACA; leg
MCA; face, arm
PCA; visual
Haemorrhagic; features of acute raised ICP, irritable
Stroke | Management
Immediate
Ischaemic vs. haemorrhagic
Urgent transfer to stroke centre
[Acute: ischaemic]
CT confirmed ischaemic stroke
Thrombolysis within 4.5hrs with altepase (tPA)
If contraindicated; aspirin
Surgery; carotid endarterectomy, carotid stenting, decompressive hemicraniectomy
[Acute: haemorrhagic]
If anticoagulated, reverse this with appropriate Tx
If ICH onset within 6hrs + SBP >150; IV labetalol until SBP <140, maintain for 7/7
Admit to HASU/ICU for close monitoring, OR
Surgery; evacuation of haematoma
Falls | Risk Assessment
Hx, age >65yrs ≥1x fall in last 12/12 Gait, balance, mobility, muscle weakness Osteoporosis risk Functional ability Fear of falling Visual impairment Cognitive assessment Neurological examination CV examination Urinary incontinence Home hazards Medication review/polypharmacy
Osteoporosis | RFs
Older age Female Low BMI Postmenopausal status Corticosteroid use Secondary amenorrhoea Immobility Vit D deficiency Hyperthyroidism Smoking Alcohol
Syncope | Aetiology
Temporary LOC due to fall in BP
Postural hypotension Carotid sinus hypersensitivity Cardiac arrhythmias Structural heart abnormalities Vasovagal syncope
Blackout | History taking
Before
During
After
[Before]
Position; lying, sitting, standing
Activity; change in posture, exercise, micturition
Predisposing; warm environment, prolonged standing
Precipitating; concurrent illness, unpleasant stimuli
Prodromal symptoms; feeling warm, nauseated, blurred vision
[During] How they fell; floppy, rigid Colour; pale, cyanosed Jerking; tonic-clonic movements, duration Tongue biting Incontinence
[After]
How they were when they came around; confused, drowsy
Recovery time; quick, prolonged
Falls | Investigations
Bedside
Bloods
Imaging
[Bedside] Obs Lying/standing BP Visual assessment Cardio/CN/neuro Urine dip ECG; AF, AS, brady, BBB AMT/4AT BG; hypoglycaemia
[Bloods] FBC, U&Es LFTs; alcohol Bone profile Echocardiogram
[Imaging]
CXR; pneumonia
CT head
Echo
Parkinson’s disease | Differentials
Essential tremor; bilateral symmetrical, head/neck/voice, worse with stress, FH +ve, improves with alcohol
Drug-induced; acute onset, symmetrical, hypomimia
CVA;
Lewy body dementia; visual hallucinations, dementia precedes Parkinsonism
Vascular parkinsonism; (LL signs) walking difficulty, memory problems, urinary incontinence, CV RFs (ddx: NPH)
PSP; early dysphagia, vertical gaze palsy, recurrent falls
Multiple system atrophy; symmetrical Parkinsonism with early postural hypotension/autonomic instability
NPH; dementia, incontinence, ataxia
CBD; asymmetrical, dyspraxia, cognitive impairment
Wilson’s disease; young, tremor, ataxia, dystonia, liver disease
Hyperthyroidism; tremor, heat intolerance, SOB, palpitations, TATT, restless, etc.
Stroke | Thrombolysis criteria
Inclusion
Exclusion
[Inclusion] Symptoms of acute stroke Onset within last 4.5hrs Neurological deficit measurable on NIHSS Absence of haemorrhage on CT
[Exclusion] Symptoms of SAH Head trauma, neurosurgery, or stroke in last 3/12 Recent major surgery in last 2/52 Hx intracranial haemorrhage, cerebral aneurysm, AVM Active bleeding elsewhere Recent LP Pregnant Anitcoagulation
TIA | Clinical features
Sudden onset loss of function Lasting minutes-hours Complete resolution of symptoms within 24hrs Hemiparesis Dysphasia Amaurosis fugax
Stroke/TIA | Aetiology
Ischaemic
Haemorrhagic
[Ischaemic]
Thrombotic; ICA thrombus lodged in MCA
Carotid artery stenosis; embolic source
Cardiogenic emboli; AF, valvular disease, infective endocarditis, atrial myxoma
[Haemorrhagic]
Intracerebral haemorrhage; trauma, HTN
SAH; aneurysms, AVM
TIA | Differentials
No LOC
Syncope
Focal seizures
Migraine
Hypoglycaemia
Retinal haemorrhage/detachment
Temporal arteritis
ABCD2 score | Risk of stroke following TIA
Management
All patients
>4
A: age >60yrs (1)
B: BP >140/90 (1)
C: clinical features of TIA; unilateral weakness (2), isolated speech disturbance (1)
D1; duration of symptoms >60mins (2), 10-59mins (1), <10mins (0)
D2; diabetes (1)
Risk of stroke at 2/7
Low 0-3; 1%
Moderate 4-5; 4%
High 6-7; 8%
[Management]
Low-mod risk; urgent referral to TIA clinic within 24hrs, aspirin 300mg OD, no driving for 1/12
High risk; admit for further investigations/imaging and secondary prevention, consult neurology
SAH | Clinical features & Investigations
Sudden onset severe headache
Altered neurological state
[Investigations]
CT head
LP; xanthochromia
CT/MR angiography
Parkinson’s disease | Counselling
Progressive neurological condition, means it causes problems in the brain that gets worse over time
A particular group of nerve cells in the brain are lost over time
These nerve cells produce a chemical called dopamine
Dopamine is responsible for many things in our bodies, but plays a big role in coordinating movement
Symptoms start to appear when the brain cannot make enough dopamine to control movement properly
Such as slowing of movement, muscle stiffness, and shaking
Combination of genetic and environmental factors
Parkinson’s disease | Counselling
Will I get better?
Is there a cure?
Will I die from Parkinson’s?
Generally gets worse over time, but everyone’s Parkinson’s progresses differently and it is difficult to say for sure
At the moment, there is no cure but there are many different treatments and support available to help manage the condition and lead a near-normal life
Most people’s life expectancy won’t change much
But some more advanced symptoms can lead to increased disability and poor health which can make you more vulnerable to infection
