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Phase 3a - Arun&Erin > COTE > Flashcards

COTE Flashcards

1
Q

Name the 2 types of cerebrovascular accidents

A
  • Ischaemic stroke
  • Haemorrhagic stroke
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2
Q

Name 4 things that can disrupt the blood supply to the brain

A
  • Thrombus/embolus
  • Atherosclerosis
  • Shock
  • Vasculitis
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3
Q

What is a TIA?

A

Temporary (< 24hrs) neurological dysfunction caused by ischaemia without infarction

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4
Q

Name 6 symptoms of stroke

A
  • Limb weakness
  • Facial weakness
  • Dysphasia
  • Visual field defects
  • Sensory loss
  • Ataxia
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5
Q

Name 5 risk factors for stroke

A
  • Previous stroke or TIA
  • Atrial Fibrillation
  • Carotid artery stenosis
  • Hypertension
  • Diabetes
  • Raised cholesterol
  • Family Hx
  • Smoking
  • Obesity
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6
Q

What is the FAST tool for stroke?

A

Face
Arm
Speech
Time

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7
Q

Tx: What is the management of a TIA?

A
  • Aspirin 300mg daily
  • Referral for specialist assessment
  • Diffusion-weighted MRI scan
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8
Q

Tx: What is the immediate management of a stroke?

A
  • Immediate CT brain (to exclude haemorrhage)
  • Aspirin 300mg daily for 2 weeks + clopidogrel
  • Admission to a specialist stroke centre
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9
Q

Tx: What management is considered once haemorrhage is excluded?

A

Thrombolysis with alteplase

  • Alteplase is a tissue plasminogen activator that rapidly breaks down clots
  • It may be given within 4.5hrs of symptom onset

Thrombectomy
* Considered in patients with a confirmed blockage of the proximal anterior/posterior circulation
* It may be considered within 24hrs of symptom onset and alongside IV thrombolysis

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10
Q

Ix: Name 2 things that are always investigated for in patients who have had a TIA or stroke

A
  • Carotid artery stenosis: carotid imaging
  • Atrial fibrillation: ECG

Anticoagulation is initiated for AF (after excluding haemorrhage and finishing 2 weeks of aspirin)
Surgical interventions are considered for significant CAS (carotid endarterectomy or angioplasty and stenting)

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11
Q

Tx: What is the secondary prevention of a stroke?

A
  • Clopidogrel 75mg once daily
  • Atorvastatin 20-80mg (not started immediately, usually delayed by at least 48hrs)
  • Blood pressure and diabetes control
  • Addressing modifiable risk factors (smoking, obesity, exercise)
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12
Q

Name 5 members involved in the MTD for stroke patients’ rehabilitation?

A
  • Stroke physicians
  • Nurses
  • Speech and Language therapists
  • Physiotherapy
  • Dieticians
  • Occupational therapy
  • Social services
  • Optometry and ophthalmology
  • Psychology
  • Orthotics
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13
Q

Definition: Parkinson’s disease

A

Condition where there is a progressive reduction in dopamine in the basal ganglia leading to disorders of movement

Sx are asymmetrical

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14
Q

What is the classic triad of Parkinson’s disease features?

A
  • Resting tremor: worse at rest
  • Rigidity: resisting passive movement
  • Bradykinesia: slow movement
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15
Q

Name 5 clinical features of Parkinson’s disease (8)

A
  • Pin-rolling tremor
  • Cogwheel rigidity
  • Bradykinesia: shuffling gait, micrographia, festinating gait, difficulty initiating movement, difficulty turning around, reduced facial movements/expressions
  • Depression
  • Insomnia
  • Anosmia
  • Postural instability
  • Cognitive impairment/ memory problems
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16
Q

Tx: What are the 4 medical treatment options for Parkinson’s disease?

A
  • Levodopa + peripheral decarboxylase inhibitor (e.g. carbidopa, benserazide)
  • COMT inhibitors
  • Dopamine agonists
  • Monoamine oxidase-B inhibitors
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17
Q

What is Levodopa?

A
  • Synthetic dopamine
  • Combined with a peripheral decarboxylase inhibitor which stops it from being metabolised before it reaches the brain
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18
Q

Name 2 combination drugs to treat Parkinson’s

A
  • Co-beneldopa (levodopa + benserazide)
  • Co-careldopa (levodopa + carbidopa)
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19
Q

What is the main SE of Levodopa and it’s Tx?

A

SE: Dyskinesia
Tx: Amantadine (glutamate antagonist)

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20
Q

Definition: Dyskinesia

A

Abnormal movements associated with excessive motor activity:

  • Dystonia: excessive muscle contraction leads to abnormal postures/exaggerated movements
  • Chorea: abnormal involuntary movements, jerking
  • Athetosis: involuntary twisting/writhing movements, usually in fingers/hands/feet
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21
Q

What are COMT inhibitors?

A

e.g. entacapone

  • Inhibits catechol-o-methyltransferase which metabolises levodopa
  • Taken with Levodopa to slow breakdown in the brain
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22
Q

What are dopamine agonists?

A
  • Mimic action of dopamine in the basal ganglia, stimulating dopamine receptors
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23
Q

Name 3 dopamine agonists

A
  • Bromocriptine
  • Cabergoline
  • Pergolide
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24
Q

What is the main SE of prolonged dopamine agonist use?

A

Pulmonary fibrosis

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25
Q

What are monoamine oxidase-B inhibitors?

A
  • Block the action of monoamine oxidase-B enzymes which break down the neurotransmitter dopamine

Monoamine oxidase enzymes break down other neurotransmitters such as serotonin and adrenaline, but monoamine oxidase-B is specific to dopamine

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26
Q

Name 2 examples of monoamine oxidase-B inhibitors

A
  • Selegiline
  • Rasagiline
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27
Q

What information should be gathered in a fall history?

A
  • Who?
  • When?
  • Where?
  • What happened before/after fall?
  • Why do they think they fell?
  • How many times have they fallen in the last 6 months?
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28
Q

What are 7 things you would ask in a systems enquiry in a fall Hx

A
  • General: wt loss, fatigue
  • Cardio: chest pain, palpitations
  • Resp: SOB, cough
  • Neuro: loss of consciousness, seizures, motor/sensory disturbance
  • GU: incontinence, urgency, dysuria
  • GI: abdo pain, diarrhoea, constipation
  • MSK: joint pain, muscle weakness
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29
Q

What 7 things would you ask in PMH for a fall?

A
  • General: visual/hearing impairment, diabetes, anaemia
  • Cardio: CVD, arrhythmias
  • Resp: COPD
  • Neuro: parkinson’s, peripheral neuropathy, stroke, dementia
  • GU: recurrent UTI, incontinence
  • GI: diverticulitis, chronic diarrhoea, alcoholic LD
  • MSK: arthritis, chronic pain, fractures
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30
Q

Name 5 medications which can cause falls

A
  • Beta-blockers (bradycardia)
  • anti epileptics (sedative)
  • Antihypertensives (hypotension)
  • Benzodiazepines (sedation)
  • Antibiotics (intercurrent infection)
  • diabetic medication (hypoglycaemia)
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31
Q

Name 4 investigations for falls

A
  • Bedside: vital signs, lying/standing BP, urine dipstick, ECG, blood glucose
  • Bloods: FBC, U&E, LFT, bone profile
  • Imaging: chest x-ray, CT head, ECHO
  • Specialist: tilt table test, Dix-Hallpike test, 48hr tape cardiac monitoring
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32
Q

Name 6 differentials for a fall

A
  • Mechanical: poor footwear, visual impairment
  • Polypharmacy
  • Stroke
  • Peripheral neuropathy
  • Hypoglycaemia
  • BPPV
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33
Q

Tx: Name 5 possible interventions to stop a fall? (10)

A
  • Gait = physiotherapy
  • Visual/ hearing problems = eye/hearing test
  • Reduce unneccessary meds
  • Alcohol cessation
  • Cognitive impairment = refer to psychiatric team
  • Postural hypotension = review meds, imrove hydration
  • Treat/rule out infections
  • Ensure good fitting footwear
  • Environmental hazards = turn on lights, take up rugs
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34
Q

Definition: Urinary incontinence

A

Loss of control of urination
Two types:
* Urge (overactivity of detrusor muscle)
* Stress (weak pelvic floor and sphincter muscles - leakage)

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35
Q

Name 5 risk factors for urinary incontinence (8)

A
  • Increased age
  • Postmenopause
  • Increased BMI
  • previous pregnancy
  • Pelvic organ prolapse
  • Pelvic floor surgery
  • Neuro conditions e.g. MS
  • Cognitive impairment & dementia
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36
Q

Name 4 investigations for urinary incontinence

A
  • Bladder diary
  • Urine dipstick
  • Post-void residual bladder volume
  • Urodynamic testing
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37
Q

Tx: What is the management of stress incontinence?

A
  • Avoid caffeine, diuretics, excessive fluid intake
  • Weight loss
  • Pelvic floor exercises
  • Surgery
  • Duloxetine - 2nd line
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38
Q

Tx: What is the management of urge incontinence?

A
  • Bladder training for at least 6 weeks
  • Anticholinergic meds (oxybutynin, tolterodine, solifenacin)
  • Mirabegron (alternative to anticholinergic)
  • Invasive procedures when medical Tx fails e.g sacral nerve stimulation/ Botox
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39
Q

Definition: Osteoporosis

A
  • Significant reduction in bone density
  • T-score of < -2.5
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40
Q

What is a DEXA scan?

A
  • Dual-energy x-ray absorptiometry
  • Measures how much raditaion is absorbed by the bones
  • Used to measure bone mineral density (BMD)
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41
Q

Name 5 risk factors for osteoporosis (10)

A
  • Older
  • Post-menopausal
  • Reduced mobility/activity
  • Low BMI
  • Low calcium/vit D
  • Alcohol & smoking
  • Personal/Family Hx of fractures
  • Chronic diseases - e.g coeliac, diabetes
  • Long-term corticosteroids
  • Certain meds (SSRI, PPI, anti-epileptics, anti-oestrogens)
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42
Q

What are QFracture tool and FRAX tool used for?

A

Calculating the 10 year risk of a major osteoporotic fracture and a hip fracture

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43
Q

Tx: What is the management of osteoporosis?

A
  • Address reversible risk factors - e.g excercise, weight, stop smoking
  • Address insufficient intake of calcium & vit D e.g supplements
  • Bisphosphonates
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44
Q

Name 4 side effects of bisphosphonates

A
  • Reflux / oesophageal erosions
  • Atypical fractures
  • Osteonecrosis of the jaw
  • Osteonecrosis of the external auditory canal
45
Q

How should oral bisphosphonates be taken?

A
  • On an empty stomach with a full glass of water
  • Afterwards pt should sit upright for 30 mins before moving/eating
46
Q

Name 3 examples of bisphosphonates

A
  • Alendronate
  • Risedronate
  • Zoledronic acid
47
Q

What is the Waterlow Score used for?

A

Risk assessment tool for estimating a pt’s risk of developing a pressure ulcer

48
Q

Definition: Pressure ulcer

A

Areas of skin necrosis due to pressure-induced ischaemia

49
Q

Name 5 risk factors for developing a pressure ulcer (9)

A
  • Age
  • Immobility
  • Low/high body weight
  • Malnutrition
  • Dehydration
  • Incontinence
  • Neurological damage
  • Sedative drugs
  • Vascular impairment
50
Q

Name the 4 mechanisms of pressure ulcers

A
  • Pressure
  • Shear: where skin is pulled away from skeleton small blood vessels can be kinked/torn
  • Friction: rubbing the skin decreases its integrity
  • Moisture: sweat, urine, faeces cause maceration adn decrease integrity
51
Q

Tx: What is the management of pressure ulcers?

A
  • Prevention
  • Turning & handling
  • Pressure-relieving devices
  • Debridement: dead tissue should be removed
  • Manage nutrition, incontinence, glycaemic control, correct anaemia
  • Dressings
  • Antibiotics
52
Q

Name 4 administration challenges when prescribing for the elderly

A
  • Labels too small to read / packaging hard to access / easy to muddle up tablets
  • Distribution: low lean body mass means dose should be adjusted if drug has a narrow therapeutic index
  • Hepatic metabolism
  • Renal excretion declines with age
53
Q

Definition: Deprivation of Liberty Safeguards

A

DoLS protect people in care homes/hospitals from being inappropriately deprived of their liberty if they cannot consent to their care arrangements.

54
Q

Definition: Power of Attorney

A

A legal document that allows an adult to nominate another person to conduct financial affairs/ health and welfare on their behalf

55
Q

Definition: Advance directive

A

A patient-led medical decision made when the pt is competent, which comes into force if the pt becomes incompetent

56
Q

Drugs that can cause postural HTN

A

Nitrates
Diuretics
Anticholinergic medications
Antidepressants
Beta-blockers
L-Dopa
Angiotensin-converting enzyme inhibitors - (ACE) inhibitors

57
Q

Medications that can cause falls other than due to postural hypotension

A

Codeine
Benzodiazepines
Digoxin
Antipsychotics

58
Q

FRIED phenotype for frailty

A

Fatigue
Low physical activity
Exhaustion
Weakness
Unintentional weight loss
Slowness in walking speed

59
Q

Risk factors for a fall

A
  • +65 years old
  • arthritis in lower limbs
  • postural hypotension
  • polypharmacy
  • peripheral neuropathy
  • vision problems
  • incontinence - constantly needing to get up
  • MS/GBS
    -hazardous environment e.g not clean
    -delirium and dementia
60
Q

Tests for falls

A

Turn 180 test

Timed up and go test more than 12 seconds

61
Q

What is breakthrough pain?

A

Transient increase in pain intensity over and above background pain - rapid, severe

i.e a flare up in a chronic condition

62
Q

What are the 2 main subtypes o fpain

A
  • Nociceptive - somatic, visceral (organs)
  • Neuropathic - nerves
63
Q

What is nociceptive pain

A

Pain which is transmitted by damaged non-neural tissue

64
Q

What is neuropathic pain?

A

Pain which is transmitted by a damaged nervous system

65
Q

What are the features of neuropathic pain?

A
  • burning
  • tingling
  • shotting
  • electric-shock
  • ‘vice-like’ (tight, like a corset)
66
Q

What is the mechanism of paracetamol?

A

Inhibits production of CNS prostaglandins

67
Q

What is the mechanism of NSAIDs?

A
  • Inhibit COX (main enzyme in synthesis of prostaglandins from arachidonic acid)
  • Can be selective (celecoxib) or non-selective (ibuprofen)
68
Q

What should you consider before prescribing paracetamol?

A
  • Liver impairment
  • Severe cachexia
69
Q

What should you check before prescribing NSAIDs?

A

Renal and platelet count

70
Q

What are the contraindications to NSAIDs?

A
  • GI bleeding/ulcer Hx
  • Asthma
71
Q

What medications interact with NSAIDs?

increase risk of bleeding

A
  • Warfarin
  • Digoxin
  • Steroids
72
Q

What should you consider when commencing opioids?

11 things (think pharmaceutical and social Hx)

A
  • Route
  • Timing
  • Renal function
  • Previous opiod use
  • Allergies
  • Acceptability of SE
  • Polypharmacy
  • Previous addiction
  • Safety of medicine in the home
  • Patient concerns
  • Driving/ occupation
73
Q

Side effects of opioids?

common (4), less frequent (3), rare (3)

A

Common
* consipation
* nausea
* sedation
* dry mouth

Less frequent
* psychomimetic effects
* confusion
* myoclonus

Rare
* allergy
* respiratory depression
* pruritus

74
Q

What are the indications of patches? (fentanyl/buprenorphine)

A
  • Intolerable SE
  • Oral route difficulties: compliance or dysphagia
  • Renal impairment
75
Q

Why wouldn’t you use a patch in acute or unstable pain?

A

Takes minimum 3 days to reach analgesic concentrations when increased

76
Q

What are the long term harms of opioids?

A
  • Falls/fractures
  • Sensitivity
  • Immune system
  • Endocrine
  • Hyperalgesia
  • Dependence
77
Q

What are antidepressants useful in? Give 2 examples

(in terms of pain Mx)

A

Neuropathic pain
* amitriptyline
* duloxetine

78
Q

What are antiepileptics useful in? Give 2 examples

(in terms of pain Mx)

A

Neuropathic pain
* pregabalin
* gabapentin

79
Q

What are antispasmodics useful in? Give 2 examples

(in terms of pain Mx)

A

Muscle spasms
* baclofen
* tizinidine

80
Q

What are steroids useful in? Give an example

(in terms of pain Mx)

A

Compression Sx
* dexamethasone

81
Q

What are benzodiazepines useful in? Give 2 examples

(in terms of pain Mx)

A

Spasms, ?neuropathic pain
* clonazepam
* diazepam

82
Q

What are local anaesthetics useful in? Give an example

(in terms of pain Mx)

A

Focal areas of pain
* topical lidocaine plasters

83
Q

What are bisphosphonates useful in? Give an example

(in terms of pain Mx)

A

Bone pain
* zolendronic acid

84
Q

What are some common palliative emergencies?

A
  • Febrile neutropenia
  • SVCO (superior vena cava obstruction)
  • Stridor
  • Hypercalcaemia
  • Spinal cord compression
85
Q

What is neutropenic sepsis/febrile neutropenia?

A

Life-threatening complication of neutropenia following chemotherapy

86
Q

What are the signs of neutropenic sepsis?

A
  • Clinical sepsis - temp >38 degrees
  • Clinical infection - chest, urine, skin, GI
87
Q

How is neutropenic sepsis diagnosed?

A
  • Clinical sepsis and/or pyrexia >38C
  • Neutrophil count < 0.5
88
Q

What is the management of neutropenic sepsis?

A
  • IV access
  • Broad spec ABx
  • Fluid resus
  • close observation & Ix (FBC, U&E, LFT, CRP, lactate, cultures)
89
Q

What signs would make you think of superior vena cava?

A

Lung cancer/tumour involving the R upper lobe or mediastinum

90
Q

What are the symptoms of SVCO?

A
  • Facial swelling, redness
  • Periorbital oedema
  • Arm swelling
  • Breathlessness
  • Distended veins on chest
91
Q

How is SVCO diagnosed?

92
Q

How is SVCO managed?

A
  • ABCs
  • High dose steroids - dexamethasone
  • consider anticoagulation
  • stenting
  • radiotherapy (or chemo)
93
Q

What signs would make you think of stridor?

A
  • Head and neck tumour
  • Lung or upper GI tumour
  • usually will hear it straight away
94
Q

What are the signs of stridor?

A
  • Noisy breathing - on inspiration
  • Harsh breath sounds
  • Breathlessness (can be a late sign of decompensation)
95
Q

How is stridor diagnosed?

A
  • Clinically
  • Upper airway visualisation
  • Upper airway imaging (CT)
96
Q

How is stridor managed?

A
  • ABC: oxygen/heliox
  • High dose steroids: dexamethasone
  • Urgent ENT/oncology review
  • Tracheostomy (new airway)
  • Stenting (open airway)
  • Radiotherapy
97
Q

What signs make you think of malignant hypercalcaemia?

A

Cancers which has spread to bone:
* breast
* lung
* kidney
* thyroid
* prostate

98
Q

What are some acute and chronic symptoms of malignant hypercalcaemia?

A

Acute:
* thirst
* confusion
* constipation
* global deterioration

Chronic:
* Depression
* Abdo pain
* Constipation
* Calculi

99
Q

How is malignant hypercalcaemia diagnosed?

A

Blood test
* corrected calcium > 2.6 = abnormal
* corrected calcium >2.8 = usually symptomatic

100
Q

How is malignant hypercalcaemia managed?

A
  • IV fluids - immediate priority (lowers serum calcium)
  • IV bisphosphonate (returns calcium to bone)
  • If resistant to bisphosphonate –> denosumab
101
Q

What signs make you think of malignant spinal cord compression?

A
  • Cancer which has spread to bone - breast, lung, kidney, thyroid, prostate
  • Primary lesions affecting spine (much less common)
102
Q

What are some signs of malignant spinal cord compression?

depends on level, but generally…

A
  • Parasthesia/sensory loss
  • Weakness/functional loss
  • Cauda equina syndrome
  • Loss of bladder/bowel function
  • Back pain
  • can be non-specific
103
Q

How is malignant spinal cord compression diagnosed?

A

MRI spine - GS
* if can’t have MRI, then CT +/- myelography

104
Q

What is the management of malignant spinal cord compression?

A
  • High dose steroids - dexamethasone
  • Radiotherapy
  • Surgery
105
Q

How should a massive haemorrhage be managed in a palliative patient?

A
  • Stop anticoagulation
  • Dark towels
  • Remain with patient
  • Midazolam 10mg stat
106
Q

What are the signs of opioid overdose in a palliative patient?

A

Toxicity:
* reduced level of consciousness
* reduced resp rate/SpO2
* Myoclonic jerks
* Pinpoint pupils

SE:
* confusion
* hallucinations
* N+V
* constipation

107
Q

How is opioid overdose managed in a palliative patient?

A
  • Naloxone - dilute 400mcg in 10ml N saline and give 20mcg every 2 mins until resp function/conscious level improves
  • Close observation
108
Q

Why wouldn’t you give naloxone to a dying patient?

A

Can precipitate sudden increase in pain

109
Q

When is ‘end of life’ care?

A

Last 12 months of life

Phase 3a - Arun&Erin (16 decks)

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