Ageing & Complex health Flashcards
A patient presents with symptoms suggestive of a stroke, how would you assess them?
[Introduction]
- Introduce self + Wash hands
- Patient name & DOB
- I am going to be assessing you as you have had some symptoms that suggest that something is going on in your brain. Do you have any pain at the moment?
- I will need you to undress so that I have access to your neck & UL + LL
[Initial assesment]
ABCDE
A-Airway
- Is the patient maintaining their airway?
- If NO -> Use airway opening maneouvre (Head tilt chin lift)
- Get anaesthetic input for airway
B-Breathing
- Brief respiratory exam
- RR
- Tracheal deviation
- Chest expansion
- Chest auscultation
- O2 saturations
C-Circulation
- Brief cardiovascular exam
- HR + Rhythm + Volume
- BP
- Carotid bruits + Irregular pulse (Ischaemic stroke RF)
D - Disability
- GCS Score
- Check pupils
- Measure Blood glucose
- Measure temp
E - Everything else
- Basic neurological exam + CN exam
- Gait
- Speech & Swallowing
- Identify vascular territory based on exam findings - Bamford classification:
- Total anterior circulation stroke (TACS)
- Partial anterior circulation stroke (PACS)
- Posterior circulation stroke (POCS)
- Lacunar syndrome
- Determine stroke severity using NIHSS score
What do the following Bamford classifications of stroke suggest?
TACS
[Total Anterior circulation stroke]
Large cortical stroke affecting ACA + MCA
Must have ALL:
- Unilateral weakness ± Sensory deficit of face/arm/leg
- Homonymous Hemaniopia
- Higher cerebral dysfunction (Dysphasia/Visuospatial disorder)
What do the following Bamford classification of stroke suggest?
PACS
Partial Anterior Circulation Stroke
Less severe than TACS, Only part of the Anterior circulation is affected
They have at least 2 of:
- Unilateral weakness ± sensory deficit of face/arm/legs
- Homonymous hemaniopia
- Higher cerebral dysfunction (Dysphasia/Visuospatial disorder)
What do the following Bamford classification of stroke suggest?
PCS
Posterior circulation stroke
Damage to the posterior circulation (Cerebellum & Brainstem)
They have 1 of the following:
- CN Palsy + Contralateral motor/sensory deficit
- Bilateral motor/sensory deficit
- Conjugate eye movement disorder (Horizontal gaze palsy)
- Cerebellar dysfunction (Vertigo/Nystagmus/Ataxia)
- Isolated homonymous hemaniopia
What do the following Bamford classification of stroke suggest?
Lacunar stroke
Subcortical stroke secondary to small vessel disease - No loss of higher cerebral function
Must have 1 of the following:
- Pure sensory stroke
- Pure motor stroke
- Sensory/Motor stroke combined
- Ataxic hemiparesis (Weakness/clumsiness on 1 side)
If you suspect a patient has had a stroke, what investigations should you carry out?
Identify the onset of the stroke, to determine the thrombolysis window
- Contact on-call stroke team
- CT Brain - Identify if ischaemic/haemorrhagic stroke
- ECG - Identify if AF/IHD
- Blood glucose -> Exclude hypoglycaemia
- FBC + CRP -> Exclude infection
- LFTs + Clotting profile -> Exclude clotting disorders
- May require urgent transfer to hyperacute stroke unit for thrombolysis
- If <4.5hrs
What is a TIA?
Transient ischaemic attack
- Temporary inadequacy of the circulation in part of the brain - Cerebral/retinal/spinal cord deficit
- Transient & reversible lasting <24hrs
What are the typical symptoms of a TIA?
- Neurological deficit lasting <24hrs
- Witness reports change in behaviour
- Unilateral symptoms
- Weakness affecting arm/leg/side of face
- Dysarthria - Slurred speech
- Sensory symptoms
- Amaurosis fugax
- Visual changes
What is a Crescendo TIA?
>2 episodes of TIA within a week
Treat as High risk for early stroke
If you suspect a patient has had a TIA, how would you investigate it?
- Urine dipstick - Negative
- FBC - Normal. Rule out infection
- U&E - Normal. May have abnormal electrolytes
- TSH
- ECG - Normal, May have AF
- PT/INR/APTT - Normal
- Blood glucose - Normal. Rule out hypoglycaemia
- Brain MRI w/diffusion - May show infarcts
- Carotid imaging - Duplex USS + CT Angiography
A patient presents with the following Hx, what is the most likely diagnosis. What are the differentials?
A 67-year-old man with a prior history of hypertension, diabetes, hyperlipidaemia, and a 50 pack-year smoking history noted rapid onset of right-sided weakness and subjective feeling of decreased sensation on his right side. His family reported that he seemed to have difficulty forming sentences. Symptoms were maximal within a minute and began to spontaneously abate 5 minutes later. By arrival in the emergency department 30 minutes after onset, his clinical deficits had largely resolved with the exception of a subtle weakness of his right hand. Forty minutes after presentation, all of his symptoms were completely resolved.
- TIA
- Stroke
- Hypoglycaemia
- Hyponatraemia
- Intracranial lesion - Tumour/Subdural haematoma
- Migraine
How are TIA’s managed?
Acute:
- 300mg Aspirin then 75mg daily
- After 2 weeks change to Clopidogrel 75mg
- Confirm diagnosis of TIA
- High intensity statin - Atorvastatin
Secondary Management:
- Inform patient of driving restions - No driving for 1 month, no need to inform DVLA.
- If multiple TIA’s - No driving for 3 months + Inform DVLA
- Lifestyle modification - Stop smoking + Exercise + Reduce alcohol
- BP lowering therapy if Hypertensive
- If AF -> Anticoagulation
What is used to determine the risk of stroke after a TIA?
ABCD2 score
A- Age
- >60 yrs = 1 pt
B - BP
- SBP >140mmHg ± DBP >90mmHg = 1 pt
C - Clinical features
- Unilateral weakness = 2 pts
- Speech disturbance w/o weakness = 1 pt
D - Duration of symptoms
- >1hr = 2 pts
- <1hr = 1 pt
D - Diabetes
- Yes = 1 pt
Scores:
- >4 - High risk of stroke (See within 24hrs)
- <4 - Low risk of stroke (See within 1 week)
What is Carotid stenosis?
Which area of the vascular network is most commonly affected in carotid stenosis?
Narrowing of the carotid arteries, leading to TIA/Stroke
Caused by:
- Atherosclerosis (Most common)
- Aneurysm
- Arteritis
- Carotid dissection
- Vasospasm
Bifurcation of the Common Carotid Artery
What are the typical symptoms of carotid stenosis?
- Asymptomatic
OR
- TIA/Stroke symptoms
- Contralateral weakness/sensory disturbance
- Ipsilateral loss of vision
- Dysphasia
- Aphasia
- Carotid bruit
If you suspect that a patient may have carotid stenosis, what investigations should be carried out?
- FBC - Normal
- U&E - Normal
- Duplex USS - Stenosis
- CT Angiogram - Stenosis
How is carotid stenosis managed?
Asymptomatic:
- Dual antiplatelet - Aspirin 75mg + Clopidogral 75mg
- Risk factor management - Stop smoking/Exercise/Diet modficiations
Symptomatic >70% stenosis
- Carotid endarterectomy
- Dual antiplatelet - Aspirin 75mg + Clopidogral 75mg
A patient presents with confusion suggestive of delirium, what differential diagnoses should be considered?
- Infection – UTI/Pneumonia/Meningitis/Encephalitis/Sepsis
- Stroke/Subdural haematoma/Epilepsy
- Dehydration
- Hyponatramia/Hypercalcaemia/Thryoid dysfunction
- Thiamine deficiency
- MI/Heart failure
- Drugs – Sedatives/Opiates/Steroids/Alcohol
- Malignancy/Constipation/Urinary retention
A patient presents with dizziness/vertigo. What are the differentials to consider?
- Peripheral – BPPV/Vestibular neuritis
- Viral labyrinthitis/Menieres disease
- Central – Vertebrobasilar insufficiency
- ENT – Acoustic neuroma/Chronic otitis media
- Stroke – Vertebrobasilar stroke/Cerebellar stroke
- MS/Epilepsy/Migraine
- Diuretics/Alcohol/Trimethoprim
A patient presents with a fit/fall/or LoC, what are the differentials that should be considered?
Cardiovascular:
- Postural Hypotension
- Arrythmia
- Aortic stenosis
- HOCM
- Carotid sinus hypersensitivity
Neurological:
- Seizure
- Parkinsons disease/Parkinsonism
- TIA/Stroke
- Vasovagal syncope
- MS
- Intracranial haemorrhage
Mechanical:
- Mechanical fall/Postural instability
- Drugs – Alcohol/Polypharmacy
What are the key principles for assessing mental capacity?
- Able to understand the information
- Retain the information
- Weigh up the information
- Communicate the decision
Confirm capacity – By asking patient to repeat back to you the information they have just gained in their own words. (Understanding)
What should be done if a patient is found to lack capacity?
Make decisions in their best interests, take into consideration:
- Previous expressed opinions
- Family/Friends views on what patient has expressed
Choose the least restrictive method of treatment
When doing a comprehensive geriatric assesment, what should be assessed?
- Physical health
- Mental health
- Social circumstances
- Functional ability
- Environment
Physical health
- PMHx + Co-morbidities
- Medication review + list
- Nutritional status
- Skin integrity/Pressure sores
- Falls screening
- Urinary/Faecal incontinence
Mental health conditions:
- Cognitive assesment
- Delirium assesment
- Mood + Anxiety
- Fears
Social circumstances
- Informal support/Support networks
- Formal support - e.g. care packages
- Statutory care + Eligibility
- Finances
Functional abilities
- Mobility + Transfers
- Personal/Domestic/Community/ADLs
Environment
- Housing
- Equipment/Adaptations
- Transport
- Accessibility
You are asked to complete a nutritional assesment of an elderly patient, How would you go about doing this?
Complete a MUST Score
To identify risk factors for malnutrition
Screening Qs:
- Are you able to feel yourself or do you have any problems? Who assists you?
- Can you prepare your own meals? Who assists you with this?
- Are you able to do your own shopping? Who assists you?
- Have you had any change in your weight? How much?
- Have you had any problems with your teeth/swallowing?
- What is your usual dietary intake?
MUST Score:
- Calculate BMI (Height + Weight)
* >20 kg/m2 – Obese/Normal = 0 points
* 18.5 - 20 kg/m2 = 1 point
* <18.5 BMI = 2 points
- Calculate BMI (Height + Weight)
- Note % of unexplained weight loss in past 3-6mo
* <5% = 0 points
* 5-10% = 1 point
* >10% = 2 points
- Note % of unexplained weight loss in past 3-6mo
- Is the patient acutely unwell + Has there or is there likely to be no nutritional intake for >5 days
* No = 0 points
* Yes = 2 points
- Is the patient acutely unwell + Has there or is there likely to be no nutritional intake for >5 days
What do the following MUST Scores mean? How would they be managed?
0 points
1 point
2 points
0 points – Low risk
- Routine clinical care
- Repeat screening
- Treat underlying condition
1 point – Medium risk
- Observe patient + Document dietary intake for 3 days
- If adequate intake:
- Little concern, repeat screening
- Treat underlying condition
- If Not adequate intake:
- Clinical concern
- Improve + Increase dietary intake
- Monitor + Review care plan regularly
- Treat underlying condition
2 points – High risk
- Treat (Unless imminent death)
- Refer to dietician/Nutrition support
- Increase overall dietary intake
- Monitor + Review care plan
- Treat underlying condition
What is Malnutrition?
- State of nutrition where there is deficiency or excess of energy/protein/other nutrient
- Causes measurable adverse effects on tissue/body form/function/clinical outcome
What are the common causes of malnutrition?
- Drugs – Decreased apetite/causing constipation
- Ageing – Gastric motility slowed/Decreased apetite
- Medical conditions – COPD/Heart failure/CKD/Liver disease
- Malignancy/Depression/Dementia
- Environment – Frailty/Social isolation
- Surgery/Illness
- D&V/Burns/Wounds/Fever
What is meant by the following terms?
NG tube
Gastrostomy
Parenteral v Enteral
TPN
PPN
- NG tube – Tube from nose to stomach (Nasogastric tube)
- Gastrostomy – Tube inserted from skin into the stomach (Invasive)
- Parenteral – Feeding not via the GI tract into a vein
- Enteral – Feeding via the GI tract
- TPN – Feeds into the SVC (Total Parenteral Nutrition)
- PPN – Feed into the peripheral veins (Partial Parenteral Nutrition)
What is a stroke?
- Neurological symptoms caused by disruption of the blood supply to the brain
- Focal/Global disturbance of cerebral functions
- Lasts >24hrs
What are the 2 types of stroke?
- Ischaemic stroke – Vascular occlusion/Stenosis
- Most common cause
- Intracerebral haemorrhage – Intraparenchymal ± SAH
What is an Ischaemic stroke?
What are the different causes of it?
Transient or permanent reduction in cerebral blood flow due to:
- Arterial occlusion/Stenosis
Causes:
- Large arteries – Extracranial carotid arteries/Vertebral arteries/intracranial arteries
- Small vessel – Lacunar infarcts
- Cardioembolism - Thrombus from heart
- Vessel disease – Dissection/Vasculitis/VTE
- Sickle cell disease/APS
What is a haemorrhagic stroke?
Bleed in the brain caused by chronic HTN
Due to:
- Primary spontaneous –
- Idiopathic/Anticoagulation induced
- Secondary – Vascular malformation/Cerebral tumour/Recreational drug use (Cocaine/Amphetamines)
- Haematological malignancy
- Vascular rupture – Shearing of brain tissue + adjacent vessels
Which conditions classically lead to strokes in the following patients?
Young
Old
Young patient:
- Vasculitis
- SAH
- Thrombophilia
- Venous sinus thrombosis
- Strangulation/Fibromuscular dysplasia (Leads to carotid artery dissection)
Older patient >65 yrs:
- Thrombosis in situ
- Cardiac origin emboli e.g. AF
- Atheroembolism
- CNS bleed - HTN/Injury/Aneurysm
- Vasculitis
Who classically gets strokes?
Patients with:
- HTN
- DM
- PAD
- Use of the COCP
- Post TIA
- Hyperlipidemia
- Smokers
- Heart disease – Valvular/IHD/AF
When examining a patient suspected of suffering from a stroke, what signs should you look for?
Meningism signs:
- Neck stiffness/Headache/Photophobia
- Visual changes
Raised ICP signs (Haemorrhagic stroke):
- Headache
- Coma
- Papilloedema
Ischaemic stroke:
- Carotid bruit
- AF
- HTN
A patient presents with the following history, what is the most likely diagnosis? What are the differentials?
A 70-year-old right-handed man is discovered by a family member to have difficulty speaking and comprehending spoken language, and an inability to raise his right arm. He was last known to be fully functional 1 hour ago when the family member spoke to him by phone. There is a history of treated hypertension and diabetes.
- Ischaemic stroke
- Haemorrhagic stroke
- Hypoglycaemia
- CNS tumour
- TIA
- Subdural bleed
- Hemiplegic Migraine
A patient presents with the following history, what is the most likely diagnosis? What are the differentials?
A 70-year-old man with a history of chronic hypertension and atrial fibrillation is witnessed by a family member to have nausea, vomiting, and right-sided weakness as well as difficulty speaking and comprehending language. The symptoms started with only mild slurred speech before progressing over several minutes to severe aphasia and right arm paralysis. The patient is taking warfarin.
- Haemorrhagic stroke
- Ischaemic stroke
- Hypoglycaemia
- Encephalopathy
- Hemiplegic migraine
- Seizure
A patient presents with the following Hx suggestive of stroke, what investigations should be carried out?
A 70-year-old man with a history of chronic hypertension and atrial fibrillation is witnessed by a family member to have nausea, vomiting, and right-sided weakness as well as difficulty speaking and comprehending language. The symptoms started with only mild slurred speech before progressing over several minutes to severe aphasia and right arm paralysis. The patient is taking warfarin.
-
CT Head – Rule out/in Intracerebral haemorrhage
- If CT Head is clear, but Hx suggestive of Haemorrhagic stroke – MRI Brain
- ECG + Troponin – Assess for MI/AF
- Blood glucose – Normal. Rule out hypoglycaemia
- FBC – Thrombocytopenia/Polycythemia/Anaemia
- ESR – Normal. Rule out GCA
- U&E – Normal. Rule out electrolyte imbalance LFTs + Clotting screen – Rule out coagulopathy
A patient presents with a Suspected/confirmed stroke, how would you manage this?
- O2 therapy if SATS <95%
- Blood sugar control if DM
- Manage BP
- Swallowing assesment
Ischaemic stroke:
- Within 4.5hrs + No C/I to thrombolysis
- Alteplase (Thrombolysis)
- 24hrs later - 300mg Aspirin
- >4.5hrs since onset or C/I to thrombolysis
- Aspirin 300mg acute + for 2 weeks
- Change to Clopidogrel
- If AF – Warfarin
Haemorrhagic stroke:
- Neurosurgical review – May require decompressive craniotomy
- ICU
- BP Management
What are the contraindications for thrombolysis?
- Seizure at onset of stroke
- Stroke or serious head injury 3 mo prior
- LP in last week
- Symptoms suggesting SAH
- Major surgery 2 weeks prior
- INR >1.4
What are the complications that can arise after a stroke?
- Residual neurological problems
- Neuropathic pain
- Depression/Anxiety
- Swallowing difficulty
- Cognitive impairment
- Speech/Visual impairment
- Sexual dysfunction
What are the components of the NIHSS score, used to determine stroke severity etc?
- Level of consciousness
- Orientation – Knows month + own age
- Open + Close eyes on command
- Best gaze
- Visual fields
- Facial pareisis
- Motor function R + L arm & Leg
- Limb ataxia
- Sensory
- Language
- Dysarthria
- Extinction & Inattention