Ageing & Complex health Flashcards

Question 1

Q

A patient presents with symptoms suggestive of a stroke, how would you assess them?

Answer

A

[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

Question 2

Q

What do the following Bamford classifications of stroke suggest?

TACS

Answer

A

[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)

Question 3

Q

What do the following Bamford classification of stroke suggest?

PACS

Answer

A

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)

Question 4

Q

What do the following Bamford classification of stroke suggest?

PCS

Answer

A

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

Question 5

Q

What do the following Bamford classification of stroke suggest?

Lacunar stroke

Answer

A

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)

Question 6

Q

If you suspect a patient has had a stroke, what investigations should you carry out?

Answer

A

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

Question 7

Q

What is a TIA?

Answer

A

Transient ischaemic attack

Temporary inadequacy of the circulation in part of the brain - Cerebral/retinal/spinal cord deficit
Transient & reversible lasting <24hrs

Question 8

Q

What are the typical symptoms of a TIA?

Answer

A

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

Question 9

Q

What is a Crescendo TIA?

Answer

A

>2 episodes of TIA within a week

Treat as High risk for early stroke

Question 10

Q

If you suspect a patient has had a TIA, how would you investigate it?

Answer

A

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

Question 11

Q

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.

Answer

A

TIA
Stroke
Hypoglycaemia
Hyponatraemia
Intracranial lesion - Tumour/Subdural haematoma
Migraine

Question 12

Q

How are TIA’s managed?

Answer

A

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

Question 13

Q

What is used to determine the risk of stroke after a TIA?

Answer

A

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)

Question 14

Q

What is Carotid stenosis?

Which area of the vascular network is most commonly affected in carotid stenosis?

Answer

A

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

Question 15

Q

What are the typical symptoms of carotid stenosis?

Answer

A

Asymptomatic

OR

TIA/Stroke symptoms
Contralateral weakness/sensory disturbance
Ipsilateral loss of vision
Dysphasia
Aphasia
Carotid bruit

Question 16

Q

If you suspect that a patient may have carotid stenosis, what investigations should be carried out?

Answer

A

FBC - Normal
U&E - Normal
Duplex USS - Stenosis
CT Angiogram - Stenosis

Question 17

Q

How is carotid stenosis managed?

Answer

A

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

Question 18

Q

A patient presents with confusion suggestive of delirium, what differential diagnoses should be considered?

Answer

A

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

Question 19

Q

A patient presents with dizziness/vertigo. What are the differentials to consider?

Answer

A

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

Question 20

Q

A patient presents with a fit/fall/or LoC, what are the differentials that should be considered?

Answer

A

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

Question 21

Q

What are the key principles for assessing mental capacity?

Answer

A

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)

Question 22

Q

What should be done if a patient is found to lack capacity?

Answer

A

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

Question 23

Q

When doing a comprehensive geriatric assesment, what should be assessed?

Answer

A

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

Question 24

Q

You are asked to complete a nutritional assesment of an elderly patient, How would you go about doing this?

Complete a MUST Score

Answer

A

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:

1. Calculate BMI (Height + Weight)
  * >20 kg/m2 – Obese/Normal = 0 points
  * 18.5 - 20 kg/m2 = 1 point
  * <18.5 BMI = 2 points
1. Note % of unexplained weight loss in past 3-6mo
  * <5% = 0 points
  * 5-10% = 1 point
  * >10% = 2 points
1. 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

Question 25

Q

What do the following MUST Scores mean? How would they be managed?

0 points

1 point

2 points

Answer

A

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

Question 26

Q

What is Malnutrition?

Answer

A

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

Question 27

Q

What are the common causes of malnutrition?

Answer

A

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

Question 28

Q

What is meant by the following terms?

NG tube

Gastrostomy

Parenteral v Enteral

TPN

PPN

Answer

A

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)

Question 29

Q

What is a stroke?

Answer

A

Neurological symptoms caused by disruption of the blood supply to the brain
Focal/Global disturbance of cerebral functions
Lasts >24hrs

Question 30

Q

What are the 2 types of stroke?

Answer

A

Ischaemic stroke – Vascular occlusion/Stenosis
- Most common cause
Intracerebral haemorrhage – Intraparenchymal ± SAH

Question 31

Q

What is an Ischaemic stroke?

What are the different causes of it?

Answer

A

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

Question 32

Q

What is a haemorrhagic stroke?

Answer

A

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

Question 33

Q

Which conditions classically lead to strokes in the following patients?

Young

Old

Answer

A

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

Question 34

Q

Who classically gets strokes?

Answer

A

Patients with:

HTN
DM
PAD
Use of the COCP
Post TIA
Hyperlipidemia
Smokers
Heart disease – Valvular/IHD/AF

Question 35

Q

When examining a patient suspected of suffering from a stroke, what signs should you look for?

Answer

A

Meningism signs:

Neck stiffness/Headache/Photophobia
Visual changes

Raised ICP signs (Haemorrhagic stroke):

Headache
Coma
Papilloedema

Ischaemic stroke:

Carotid bruit
AF
HTN

Question 36

Q

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.

Answer

A

Ischaemic stroke
Haemorrhagic stroke
Hypoglycaemia
CNS tumour
TIA
Subdural bleed
Hemiplegic Migraine

Question 37

Q

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.

Answer

A

Haemorrhagic stroke
Ischaemic stroke
Hypoglycaemia
Encephalopathy
Hemiplegic migraine
Seizure

Question 38

Q

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.

Answer

A

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

Question 39

Q

A patient presents with a Suspected/confirmed stroke, how would you manage this?

Answer

A

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

Question 40

Q

What are the contraindications for thrombolysis?

Answer

A

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

Question 41

Q

What are the complications that can arise after a stroke?

Answer

A

Residual neurological problems
Neuropathic pain
Depression/Anxiety
Swallowing difficulty
Cognitive impairment
Speech/Visual impairment
Sexual dysfunction

Question 42

Q

What are the components of the NIHSS score, used to determine stroke severity etc?

Answer

A

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

Question 43

Q

What is Dysarthria?

Answer

A

Disorder of speech – Motor
Articulation + Pronounciation
Signifies Broca’s or Bulbar dysfunction

Question 44

Q

What is Dysphasia?

Answer

A

Disorder of language - thoughts + ideas that are spoken

Receptive:

Difficulty in comprehension

Expressive:

Difficulty putting words together to form meaning

Question 45

Q

What can be seen on a CT scan in a patient with a stroke?

Answer

A

Hyperdense artery – Suggests clot
Hypodense cortex – Ischaemic damage
- May have cytotoxic oedema surrounding area
Hyperdense lesion in cortex – Haemorrhagic stroke

Question 46

Q

A patient has presented with a tremor, you are asked to assess them. How would you go about this?

Answer

A

[Introduction]

Introduce self + Wash hands
Ask patient name + DOB + Age
I am going to be doing an exam to look at how your brain is working, looking at your arms and legs, as well as your walking
- Is that ok?
- Any pain at the moment?
I will need to be able to see your arms ± legs so I will need you to undress accordingly

[General inspection]

I will start the examination by looking at you from the end of the bed, looking for:
- Walking aids
Looking at the patient:
- Any obvious tremor – Fine or Coarse

[Tremor]

Assess for resting tremor:
- Can you rest your hands on your lap and close your eyes
- Count down from 20
- Assess if tremor
- Ask to lift opposite hand up and down on lap (Synkinesis)
Assess for postural tremor:
- Can you hold your arms out in front of you
- If tremor worsens – Postural tremor
- Hold palms out facing me – Flapping tremor
Assess for action tremor:
- Can you pick up a pen lid from out of my hand or pick up a glass of water
- Ask patient to move finger from my hand to their nose
- Test other side
Assess for bradykinesia:
- Can you spread your index finger + thumb as wide as you can
- Can you tap them together rapidly and repetitively (Opposition)
- Watch for reduction in speed of movement + rhythm + amplitude

[Gait]

Can you get up and walk up and down the room for me, ill watch from here. Do you need any mobility aids?
Assess gait for:
- Shuffling gait
- Hesitant gait (Difficulty starting + turning)
- Festinant gait (Walks faster + faster so they dont fall over)
- Lack of arm swing (Increased tone)
- Unsteadiness - tend to fall
- Freezing - Stop whilst moving

[Face]

Can you take a seat on the exam couch now for me
- Observe face:
- Hypomima
- Any drooling
Glabellar tap:
- Repeatedly tap on forehead - should blink in response to 1st tap then stop
- Note if blinking continues within continued tapping
Eye movements:
- Test eye movements with H test
- Note for:
  - Vertical gaze palsy
  - Nystagmus
Assess speech:
- Can you count down from 100 please
- Listen for softening of speech + faint (Hypophonia)
- Slowing down of thought
- Can you say baby hippopotamus + British Constitution
- Assess for dysarthria/Staccato speech

[Rigidity/Limb exams]

Assess UL/LL tone, looking for:
- Increased tone (Spasticity/Rigidity)
- Test with synkinesis (if no Increased tone)
Test bradykinesia:
- In UL – Can you touch your thumb to your index finger repeatedly
- In LL – Can you tap the bed with your heel repeatedly
- Look for – Slowing of movement

[Power/Reflexes/Sensation]

Assess to see if there is any dysfunction in these

[Other tests]

Check for postural hypotension – Lying + Standing BP
Check writing for micrographia
Cognitive testing – MMSE
Drug Hx

[Complete exam]

Thank patient + Wash hands
I would take a full Hx + full neurological examination
Differentials
Investigations
Management

Question 47

Q

What signs would you expect on examination in a patient with Idiopathic parkinsons disease?

Answer

A

Unilateral coarse pill rolling tremor
Resting tremor
Bradykinesia
Gait problems – Shuffling/Hesitant/Festinant/Lack of arm swing/Unsteadiness/Freezing
Hypomima/Drooling
Continued blinking on Glabellar tap
Hypophonia/Dysarthria/Stacatto speech
Cogwheel rigidity
Normal Power/Reflexes/Sensations
Micrographia

Question 48

Q

What are the following signs of?

Postural tremor
Flapping tremor
Action tremor
Vertical gaze palsy
Nystagmus
Dysarthria/Staccato speech
Orthostatic hypotension
Decreased cognition
DHx

Answer

A

Postural tremor – MS
Flapping tremor – Hepatic/Respiratory/Renal failure
Action tremor – Physiological tremor
Vertical gaze palsy – PSP
Nystagmus – MSA/Cerebellar pathology
Dysarthria/Staccato speech – Cerebellar pathology
Orthostatic hypotension – Degenerative PD/MSA
Decreased cognition – Lewy body dementia
DHx of parkinsonism drug – Drug induced parkinsonism

Question 49

Q

What is Idiopathic Parkinsons disease?

Answer

A

Movement disorder due to the degeneration of dopaminergic pathways in the basal ganglia leads to overall decreased dopamine available

Characterised by TRAP:

Tremor at rest
Rigidity
Akinesia/Bradykinesia
Postural instability

Question 50

Q

What causes Idiopathic parkinsons?

Answer

A

Selective loss of Nigrostriatal dopaminergic neurons in Substantia nigra of basal ganglia

Deposits of protein synuclein
Decreased activity of direct pathway
Increased activity of indirect pathway

Lead to increased inhibition of movement to the thalamus

Question 51

Q

Who classically gets IPD?

What is the classic presentation (Symptoms/Signs) of PD?

Answer

A

>55yrs

Men > Women

Symptoms/signs:

Slow progressing neurodegeneration
- Bradykinesia
- Resting tremor
- Gait + Balance disturbance
- Hypomima (Fixed facial expression)
UMN signs - Rigidity
- Asymmetry
- Normal muscle strength
- Normal reflexes
- Down going/Absent Plantar reflex

Question 52

Q

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 69-year-old man presents with a 1-year history of mild slowness and loss of dexterity. His handwriting has become smaller, and his wife feels his face is less expressive and his voice softer. Over the last few months he has developed a subtle tremor in the right hand, noted while watching television. His symptoms developed insidiously but have mildly progressed. He has no other medical history, but he has noted some mild depression and constipation over the last 2 years. His examination demonstrates hypophonia, masked facies, decreased blink rate, micrographia, and mild right-sided bradykinesia and rigidity. An intermittent right upper extremity resting tremor is noted while he is walking. The rest of his examination and a brain MRI are normal.

Answer

A

Idiopathic Parkinsons disease
Benign essential tremor
Drug or toxin induced parkinsons
Huntingdons disease
Lewy body dementia
Wilsons disease
MSA/PSP/Vascular parkinsons

Question 53

Q

What are the diagnostic criteria for PD?

Answer

A

Muscular rigidity
Resting tremor
Postural instability
Unilateral onset
Progression
Good response to L-Dopa
Asymmetry

Question 54

Q

A patients presents with the following symptoms, suggestive of PD. What investigations should be ordered?

Answer

A

Clinical diagnosis
- Hx + Examination
- L-Dopa test for 12 weeks, symptoms should resolve
CT/MRI brain
- Exclude secondary cause + vascular pathology
DAT testing – Confirm diagnosis, but not usually used.

Question 55

Q

How is a patient with confirmed PD, managed?

Answer

A

Patient education
Inform the DVLA

Supportive management:

MDT
Physiotherapy + OT
Nurse specialist

Medical management:

Regular review 6-12 mo
Assess disability + cognition
QoL affected – Co-Careldopa/Co-Beneldopa (Dopamine + COMT)
QoL Not affected – Pramipexole/Rasagiline (MAO B inhibitor)

Question 56

Q

What are the side effects caused by long term PD management?

Answer

A

Motor fluctuations:
- On off phenomena
- Wearing off – Fluctuations in response + duration of medications
- Dyskinesia
Depression + Anxiety
Compulsive disorders
REM sleep behaviour disorder
Nocturnal akinesia

Consider drugs such as Pramipexole/Ropinirole/Selegeline/Rasagiline

Question 57

Q

What are the complications that can develop in PD in the long term?

Answer

A

Infections
Aspiration pneumonia
Bed sores
Poor nutrition
Falls
Bowel/Bladder disorders

Question 58

Q

You are asked to explain the dopaminergic drugs used for parkinsons disease (Levadopa - Co-Careldopa/Co-Beneldopa) + Ropinorole + Pramipexol). How would you do this?

Answer

A

Layout:

Check what the patient knows
Brief history
Do they know what the drug is?
Indication & Action of the drug
Side effects
How to take it
Monitoring requirements

[Indication & Action]

Indications

In early parkinson’s disease - when dopamine agonists are preferred over levodopa
Late parkinson’s disease - Levadopa, with dopamine agonists as an add on option
Secondary Parkinsonism

Action

Deficiency of dopamine in Nigrostriatal pathway - links substantial nigra in the midbrain -> Corpus striatum in Basal Ganglia
Via direct and indirect pathways
Leads the Basal ganglia to exert greater inhibition on the thalamus = reduces excitation to the motor cortex (Results in bradykinesia + Rigidity)

Treatment with agonists – Increase dopaminergic stimulation to the striatum

Dopamine itself cannot be given because it cant cross the BBB
Levadopa - precursor of dopamine can enter the brain via a membrane transporter
Ropinirole & Pramipexol -> Selective agonists for the D2 receptor - predominates in the corpus striatum

[How to take it]

Always given with peripheral dopa-decarboxylase inhibitor (Carbidopa) to reduce conversion to dopamine outside the brain
Ensure it is taken at specific times to produce the best symptom control for patient

Can be taken as:

Tablet/Transdermal patch
Best taken with food

Length - As long as it works

Effect - Fast acting

1st line dopamine agonists - ROPINIROLE + PRAMIPEXOL

Late presentation - LEVADOPA (AS CO-CARELDOPA/CO-BENELDOPA)

Co-beneldopa (Benserazide)
Co-careldopa (Carbidopa)

[Important SE]

Nausea
Drowsiness
Confusion
Hallucinations
Hypotension
Excess can lead to excessive and involuntary movements -> Dyskinesias

Levadopa specifically

Wearing off effect - patients symptoms worsen towards the end of the dosage interval
- Gets worse as duration of therapy increases
- Can be overcome by increasing dose/frequency Can lead to excessive and involuntary movements -> Dyskinesias
- This is the on-off effect

Complications/Contraindications

Use cautiously in:

Elderly
Existing cognitive/psychiatric disease -> Risk of causing confusion & hallucinations
CVD -> Risk of hypotension
Avoid combination with Typical antipsychotics & Metoclopramide

Patient will have access to specialist nurse

[Monitoring requirements]

Monitoring of SE
BP monitoring - assess for hypotension

Question 59

Q

What are the symptoms/signs in vascular parkinsonism?

How is it managed?

Answer

A

Predominant lower body signs
No stooped posture - stand straight
Tremor less common
Rigidity of LL + lack of facial expression

Management:

May respond to levadopa
Management of CVD risk factors

Question 60

Q

What are the symptoms/signs of drug induced parkinsonisms?

How is it managed?

Answer

A

Hx of dopamine blocking drug use such as anti-psychotics/metoclopramide
Symmetrical rigidity
Lack of facial expression

Management:

Reduce or stop drug if possible

Question 61

Q

What is Multiple system atrophy?

Answer

A

Neurodegenerative disorder due to cell loss in the brain + spinal cord
Leads to symptoms affecting autonomic + motor systems
Parkinsonian features + cerebellar ataxia + autonomic dysfunction

Question 62

Q

Who classically gets multiple system atrophy?

What are the symptom/signs?

Answer

A

Male > Females
Develop disease when >40yrs old

Symptoms/signs:

Urinary dysfunction
Postural hypotension – lightheaded/dizzy on standing + fainting
Cerebellar ataxia – uncoordinated movement, lack of control of voluntary movement
Poor/temporary response to levadopa
May have constipation
Neuropsychiatric symptoms – depression/insomnia/dementia

Question 63

Q

How would you investigate a patient with suspected MSA and manage them?

Answer

A

Investigations:

Clinical diagnosis, presence of:
- Autonomic features ± Urogenital features ± extrapyramidal features ± cerebellar features
MIBG Scintigraphy – Increased uptake in MSA
FDG PET scan – caudate putamen index decreased in MSA less than PD

Management:

No cure or therapy to stop progression
Manage postural hypotension
Manage constipation/incontinence/falls
Prevent deconditioning with physical activities
SALT – assist with swallowing
Levadopa for movement disorder
Patient education – poor prognosis

Question 64

Q

What is Progressive supranuclear palsy?

Answer

A

Neurodegenerative Parkinsonism syndrome affecting:
Cognition - Apathy/Disinhibition/Anxiety
Eye movements (Vertical gaze palsy, due to CN3 dysfunction)
Posture – Extrapyramidal (Postural instability + Akinesia)
Tremor
Pseudobulbar palsy

Answer 65

A

No effective therapy
May have relief from levadopa
Physiotherapy
Poor prognosis

Answer 66

A

Essential tremor

Answer 67

A

Symptoms/Signs:

Worse on movement - postural + intention
Distal + Symmetrical tremor
Familial
Jaw + Head + voice tremor
Coarse tremor
Absent at rest
Better with alcohol
No neurological signs

Investigations:

Clinical diagnosis
TFTs
U&E
FBC

Management:

Mild – No treatment
Moderate to severe – Treatment:
- Propranolol or Primidone
- Deep brain stimulation

Answer 68

A

Tremor in exagerated form due to:

Anxiety
Hyperthyroidism
Hypoglycaemia
Caffeine excess
Medications
Fever

Symptoms/Signs:

Bilateral
Symmetrical
Non-progressive over time
No other motor symptoms

Investigations:

Clinical diagnosis
TFTs
U&E
FBC

Management:

Manage causative conditon

Answer 69

A

Essential tremor
Idiopathic PD
Wilsons disease
Drug induced tremor
Physiological tremor

Answer 70

A

BP lower than usual causing symptoms such as dizziness or light-headedness

Defined as:

SBP <90mmHg
DBP <60mmHg
Can lead to syncope – Loss of consciousness due to reduced cerebral perfusion

Answer 71

A

Common in elderly due to changes to BP control (Decreased baroreflex mechanisms)
HR control + decreased vascular resistance

Symptoms/Signs:

BP <20mmHg within 3 mins of standing
Falls/Syncope
Normally asymptomatic
May have Hx of dizziness/light headedness
Blurred vision
Weakness
fatigue
Nausea
Palpitations
Headache

Answer 72

A

Cardiac/Endocrine/Neurological

Cardiac:

Aortic stenosis/Arrythmia/MI/Pericarditis/Heart failure

Endocrine:

DM
Phaechromocytoma
Primary hyperaldosteronism

Neurological:

Vasovagal syncope - prolonged standing
Vasospasm
Alcoholic neuropathy

Other:

Pregnancy
Varicose veins
Drugs affecting BP – Antidepressants/Levadopa/Alcohol/Diuretics

Answer 73

A

Investigations:

FBC
U&E
Fasting glucose
Pregnancy test - if young female
ECG
Tilt table test – diagnostic for orthostatic hypotension
Lying + standing BP

Management:

Cardiology referral if heart disease/abnormal ECG
Patient education - triggers to avoid, stand up slowly
Review medication
Compression stockings
Increase fluid intake

Answer 74

A

LPA - Legal
Advanced statement
Advanced decision/decision to refuse treatment - Legal
Best interests

Answer 75

A

Transient loss of consciousness due to transient global cerebral hypoperfusion (Decreased nutrient delivery) with rapid onset + short duration + complete recovery

Causes:

Neurally mediated syncope/Reflex syncope - most common
Orthostatic hypotension - most common
Cardiac arrythmia
Structural cardiac or Cardiopulmonary disease
Substance abuse
Psychogenic

Answer 76

A

Vasovagal syncope - due to emotional/orthostatic stress
Situational syncope - micturition/cough syncope
Carotid sinus hypersensitivity - when turning head
Glossopharyngeal neuralgia

Answer 77

A

Sick sinus syndrome/AVN disease
Paroxysmal SVT/VT
Brugada’s/Long QT syndrome
Malfunctions of ICD/Drug induced

Answer 78

A

Obstructive valvular disease
ACS
HOCM
Aortic dissection
Pericardial disease
PE/Pulmonary HTN

Answer 79

A

Syncope
Falls/Trauma
Dizziness/Vertigo
TIA/Stroke
Epilepsy
Alcohol/drug abuse

Answer 80

A

ABCDE assesment
- Cardio + Neuro + Resp exams
Observations
- BP - Lying + standing
Bloods:
- FBC - Looking for anaemia
- Blood glucose - Rule out hypoglycaemia
- Prenancy test - rule out pregnancy
- U&E – Rule out dehydration ± metabolic disturbance
- ECG – Rule out ischaemia/arrythmia
Tilt table test - diagnose orthostatic hypotension
Carotid sinus massage – rule out carotid sinus hypersensitivity

Answer 81

A

Type of dizziness, where there is a false sensation that yourself or surroundings are moving or spinning.
Due to mismatch b/w vestibular/visual/somatosensory systems

Answer 82

A

Central (Cerebral cortex/cerebellum/brainstem):

Cerebrovascular disease
Migraine
MS
Acoustic neuroma
Intoxication
Diplopia

Peripheral (Vestibular system):

Viral labrynthitis
BPPV
Vestibular neuritis
Menieres disease
Motion sickness

Answer 83

A

Viral labrynthitis
BPPV

Answer 84

A

Identify if symptoms are dizziness or vertigo?

Any associated symptoms:

Ear symptoms – Hearing loss/discharge/tinnitus
Neurological symptoms – Headache/diplopia/visual disturbance/ataxia/dysarthria or dysphasia
Autonomic symptoms – N&V/Sweating/palpitations
Migraine aura
Recent URTI or ear infection – Viral neuronitis/labrynthitis
Hx of migraine
Anxiety/Depression
Head trauma/recent labrynthitis – BPPV
CVD – Stroke

Examination:

Neurological exam
CN exam
Ear exam
Eye exam
Rombergs test
Dix Hallpike

Answer 85

A

Most common cause of vertigo, due to inner ear dysfunction
Otoliths detached from macula in SC canals - most common is Post SC
Continues to move after head stops – vertigo (Conflicting sensation with sensory input)

Caused by:

Idiopathic
Head injury
Viral neuronitis - post viral illness
Chronic middle ear disease

Answer 86

A

Any age, usually >50yrs
Women > Men

Symptoms/Signs:

Episodes of vertigo triggered by head movements
Worse when head tilted to specific side
Sudden onset + rapid resolution if head remains still
N&V
Worse in the mornings
May have falls
Vertical nystagmus (Towards forehead)
Normal ear exam
Normal CN exam
Normal Neurological exam
Dix hallpike - positive

Answer 87

A

Ask patient if any cervical spine pathology
Ask pt to keep eyes open + stare at my nose
Pt sitting with head at 45 degs, to the left (for L Post SC)
Lay patietn down until head is dependent 30 deg below level of couch
Observe for nystagmus for 30s
Return to upright position
Repeat on other side
On sitting pt experiences vertigo to confirm diagnosis

Answer 88

A

BPPV
Acute vestibular labrynthitis
Menieres disease
Acoustic neuroma
MS
TIA/Stroke
Anti-convulsant/Anti-hypertensives

Answer 89

A

Investigations:

Clinical diagnosis
Dix Hallpike manouvre - to confirm Post SC involvement (BPPV)
If uncertain - CT/MRI

Management:

Advise that symptoms are self limiting but may recur
Limit symptoms by slowly getting out of bed + decreasing head movements
Epley manouvre - can be immediate resolution, not always
Must not drive or operate heavy machinery whilst symptomatic

Answer 90

A

Used to treat BPPV - aim is to reposition the otoliths back into the utricles in the posterior SC canals
Sit pt upright on couch with head turned to 45deg to affected side
Place hands on either side of pts head and guide pt to lie down with head dependent + 30 deg over the egde of the couch
Wait for 30s - 1 min for nystagmus to resolve
Rotate head to 90deg to opposite side with pt upward but head dependent
Roll pt on side whilst holding head - rotate head to face downwards to ground
sit pt up sideways - maintain head rotation
Rotate head to central position with chin on their chest
Should be NO nystagmus
Can take days/weeks to recover or immediately

Answer 91

A

Disease of the inner ear due to change in fluid volume in the labrynth
Menieres syndrome - if cause if known
Progressive distension of membranous labryinth in inner ear leads to damage to vestibular system – vertigo + cochlea – Hearing loss

Characterised by:

Episodic sudden onset of vertigo
Low frequency hearing loss
Low frequency roaring tinnitus
Sensation of fullness in affected ear

Answer 92

A

Overproduction or under absorption of endolymph

linked to:

Food allergy
Congenital or acquired syphillis
Hypothyroidism
Acoustic/physical trauma
Internal auditory canal stenosis

Answer 93

A

40-60yrs, can happen at any age
Rare in children
Females > Males
Increased risk if: Atopy/Autoimmune condition/FHx/Recent viral illness

Symptoms/Signs:

Episodic sudden onset of vertigo
Low frequency hearing loss
Low frequency roaring tinnitus
Sensation of fullness in affected ear
Fluctuating + episodic pattern (Months of remission)
May have drop attacks – no LoC + Vertigo + Imbalance/spinning sensation

Answer 94

A

Menieres disease
BPPV/Acute vestibular neuronitis
Acoustic neuroma/OM
Vertebrobasilar insufficiency/TIA/Stroke
SoL/Migraine
Anaemia/DM

Answer 95

A

Investigations:

Clinical diagnosis - Tinnitus/Vertigo/Hearing loss
Rule out other causes:
- FBC – Normal
- ESR – Normal
- TFTs – Normal
- Syphillis screen
- Fasting glucose – Normal
- U&E – Normal
Audiometry – Sensorineural hearing loss
MRI brain – Rule out acoustic neuroma

Management:

No cure
Inform DVLA
Acute attacks:
- Prochlorperazine/Cyclizine/Promethiazine (Vertigo/Nausea)
- If severe D&V – Admission for rehydration
- Prednisolone
Prophylaxis:
- Low salt diet
- Trial betahistadine - reduce frequency/severity of attacks
- Hearing aids for hearing loss

Answer 96

A

vestibular neuritis’ be confined to cases in which the vestibular nerve only is involved, with the term ‘labyrinthitis’ being used in cases in which the vestibular nerve and the labyrinth are affected
Vestibular neuritis is a very common cause of vertigo
Vestibular neuritis is most likely a vestibular neuropathy caused by reactivation of latent type 1 herpes simplex virus in the vestibular ganglion
cases of labyrinthitis appear to be viral in origin and an upper respiratory tract infection

Answer 97

A

DAME

Drugs:

Polypharmacy
Antihypertensives/sedatives/opioids

Ageing related:

Vision changes
Cognitive decline
Gait abnormalities
OA

Medical causes:

Cardiac hypotension
Arrythmia
Neurological causes – PD/Stroke/Neuropathy
Cataracts

Environmental:

Walking aids
Footwear
Home hazards

Answer 98

A

Acute fluctuating change in mental status with inattention and disorganised thinking + altered level of consciousness
Abnormality of thought/perception/levels of awareness
Acute onset + intermittent
Life threatening

Answer 99

A

Hyperactive:

Increased arousal
Restlessness/agitation/hallucinations/innapropriate behaviour

Hypoactive:

Lethargy/Decreased motor activity
Incoherent speech or lack of interest

Mixed:

Combination of both

Answer 100

A

Disturbance in attention – decreased clarity of awareness of environment
Change in cognition (Memory deficit/disoriented/language disturbance)
Develops over a short period of time (hrs or days)
acute change from baseline/fluctuates over the course of the day
Disturbance is caused by medical conditon/drug/substance withdrawal. Not dementia

Answer 101

A

Acute infection – UTI/Sepsis/Pneumonia
Prescribed drug – Benzodiazepine/Morphine/Steroids
Post op
Alcohol/Carbon monoxide poisoning/Barbituate withdrawal
CVA/SDH/IHD
Hypoxia/Hypoglycaemia/Hepatic or renal impairment
Vitamin B12 or Thiamine deficiency
Trauma/Constipation/Urinary retention/SoL

Answer 102

A

Investigations:

MMSE - assess cognition
FBC – Infection or anaemia
U&E – Electrolyte imbalance/dehydration/renal impairment
Glucose
Ca+ levels
LFTs
TFTs
ECG + Troponin
Vitamin B12 + Folate
Urine dipstic + microscopy + culture
Blood culture
Observations - O2, HR, BP
CT brain
CXR

Management:

Treat underlying cause
Consent may be provided during lucid moments
Supportive management – Clear communication + reminders to orientate themselves + familar objects and people + relaxation
- Maintain hydration + nutrition
- Adequate space + sleep - Side room
- Ensure pt remains independent as much as possible
Acute management if agitated:
- Antipsychotics - Olanzepine/Haloperidol or Lorazepam if PD
- Diazepam if due to alcohol
May have residual disorientation/inattention

Answer 103

A

4AT test - Delirium
AMTS score
MMSE

Answer 104

A

1. Wash hands
1. Confirm the identity of the patient – check the wrist band
1. General inspection – skin colour / any obvious signs of life
1. Look for signs of respiratory effort
1. Does the patient respond to verbal stimuli? – “Hello Mr Smith, can you hear me?”
1. Does the patient respond to pain? – press on fingernail / trapezius squeeze / supraorbital pressure
1. Assess pupils using pen torch – after death they become fixed and dilated
1. Feel for a central pulse – carotid artery
1. Auscultation:
  * Listen for heart sounds for at least 2 minute
  * Listen for respiratory sounds for at least 3 minutes
  * Wash hands and exit the room

Answer 105

A

Ischaemic stroke

Hyperdense segment of vessel (Thrombus)
Loss of grey-white matter differentiation
Cortical hypodensity ± parenchymal swelling

Answer 106

A

Haemorrhagic stroke

Hyperdense collection of blood

Answer 107

A

Lacunar infarct

Ill defined hypodensities
Hypodense foci (Similar to CSF)

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Ageing & Complex health Flashcards

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