COTE Flashcards
(109 cards)
1
Q
Name the 2 types of cerebrovascular accidents
A
- Ischaemic stroke
- Haemorrhagic stroke
2
Q
Name 4 things that can disrupt the blood supply to the brain
A
- Thrombus/embolus
- Atherosclerosis
- Shock
- Vasculitis
3
Q
What is a TIA?
A
Temporary (< 24hrs) neurological dysfunction caused by ischaemia without infarction
4
Q
Name 6 symptoms of stroke
A
- Limb weakness
- Facial weakness
- Dysphasia
- Visual field defects
- Sensory loss
- Ataxia
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
6
Q
What is the FAST tool for stroke?
A
Face
Arm
Speech
Time
7
Q
Tx: What is the management of a TIA?
A
- Aspirin 300mg daily
- Referral for specialist assessment
- Diffusion-weighted MRI scan
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
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
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)
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)
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
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
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
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
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
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
18
Q
Name 2 combination drugs to treat Parkinson’s
A
- Co-beneldopa (levodopa + benserazide)
- Co-careldopa (levodopa + carbidopa)
19
Q
What is the main SE of Levodopa and it’s Tx?
A
SE: Dyskinesia
Tx: Amantadine (glutamate antagonist)
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
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
22
Q
What are dopamine agonists?
A
- Mimic action of dopamine in the basal ganglia, stimulating dopamine receptors
23
Q
Name 3 dopamine agonists
A
- Bromocriptine
- Cabergoline
- Pergolide
24
Q
What is the main SE of prolonged dopamine agonist use?
A
Pulmonary fibrosis
25
What are **monoamine oxidase-B inhibitors**?
* **Block** the action of **monoamine oxidase-B enzymes** which break down the neurotransmitter **dopamine**
## Footnote
Monoamine oxidase enzymes break down other neurotransmitters such as serotonin and adrenaline, but monoamine oxidase-B is specific to dopamine
26
Name 2 examples of monoamine oxidase-B inhibitors
* **Selegiline**
* **Rasagiline**
27
What information should be gathered in a **fall** history?
* 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?
28
What are 7 things you would ask in a **systems enquiry** in a fall Hx
* **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
29
What 7 things would you ask in **PMH** for a fall?
* **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
30
Name 5 medications which can cause falls
* **Beta-blockers** (bradycardia)
* **anti epileptics** (sedative)
* **Antihypertensives** (hypotension)
* **Benzodiazepines** (sedation)
* **Antibiotics** (intercurrent infection)
* **diabetic medication** (hypoglycaemia)
31
Name 4 investigations for falls
* **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
32
Name 6 differentials for a fall
* **Mechanical**: poor footwear, visual impairment
* **Polypharmacy**
* **Stroke**
* **Peripheral neuropathy**
* **Hypoglycaemia**
* **BPPV**
33
Tx: Name 5 possible interventions to stop a fall? (10)
* 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
34
Definition: Urinary incontinence
**Loss of control of urination**
Two types:
* Urge (**overactivity** of **detrusor muscle**)
* Stress (**weak pelvic floor** and **sphincter muscles** - leakage)
35
Name 5 risk factors for urinary incontinence (8)
* Increased age
* Postmenopause
* Increased BMI
* previous pregnancy
* Pelvic organ prolapse
* Pelvic floor surgery
* Neuro conditions e.g. MS
* Cognitive impairment & dementia
36
Name 4 investigations for urinary incontinence
* **Bladder diary**
* **Urine dipstick**
* **Post-void residual bladder volume**
* **Urodynamic testing**
37
Tx: What is the management of stress incontinence?
* Avoid caffeine, diuretics, excessive fluid intake
* Weight loss
* Pelvic floor exercises
* Surgery
* Duloxetine - 2nd line
38
Tx: What is the management of urge incontinence?
* **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
39
Definition: Osteoporosis
* Significant reduction in **bone density**
* T-score of **< -2.5**
40
What is a DEXA scan?
* Dual-energy x-ray absorptiometry
* Measures how much **raditaion** is absorbed by the bones
* Used to measure **bone mineral density** (BMD)
41
Name 5 risk factors for osteoporosis (10)
* 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)
42
What are QFracture tool and FRAX tool used for?
Calculating the **10 year risk** of a **major osteoporotic fracture** and a **hip fracture**
43
Tx: What is the management of osteoporosis?
* Address **reversible risk factors** - e.g excercise, weight, stop smoking
* Address **insufficient intake of calcium & vit D** e.g supplements
* **Bisphosphonates**
44
Name 4 side effects of **bisphosphonates**
* **Reflux** / oesophageal erosions
* **Atypical fractures**
* **Osteonecrosis** of the **jaw**
* **Osteonecrosis** of the **external auditory canal**
45
How should oral bisphosphonates be taken?
* On an **empty stomach** with a full glass of water
* Afterwards pt should **sit upright** for **30 mins** before moving/eating
46
Name 3 examples of bisphosphonates
* **Alendronate**
* **Risedronate**
* **Zoledronic acid**
47
What is the Waterlow Score used for?
Risk assessment tool for estimating a pt's risk of developing a **pressure ulcer**
48
Definition: Pressure ulcer
Areas of skin **necrosis** due to **pressure-induced ischaemia**
49
Name 5 risk factors for developing a pressure ulcer (9)
* Age
* Immobility
* Low/high body weight
* Malnutrition
* Dehydration
* Incontinence
* Neurological damage
* Sedative drugs
* Vascular impairment
50
Name the 4 mechanisms of pressure ulcers
* **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
Tx: What is the management of pressure ulcers?
* **Prevention**
* **Turning & handling**
* **Pressure-relieving devices**
* **Debridement**: dead tissue should be removed
* Manage **nutrition**, **incontinence**, **glycaemic control**, **correct anaemia**
* **Dressings**
* **Antibiotics**
52
Name 4 administration challenges when prescribing for the elderly
* 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
Definition: Deprivation of Liberty Safeguards
DoLS protect people in **care homes/hospitals** from being **inappropriately deprived of their liberty** if they cannot consent to their care arrangements.
54
Definition: Power of Attorney
A legal document that allows an adult to **nominate another person** to conduct **financial affairs**/ health and welfare on their behalf
55
Definition: Advance directive
A **patient-led** medical decision made when the pt is **competent**, which comes into force if the pt becomes **incompetent**
56
Drugs that can cause postural HTN
Nitrates
Diuretics
Anticholinergic medications
Antidepressants
Beta-blockers
L-Dopa
Angiotensin-converting enzyme inhibitors - (ACE) inhibitors
57
Medications that can cause falls other than due to postural hypotension
Codeine
Benzodiazepines
Digoxin
Antipsychotics
58
FRIED phenotype for frailty
Fatigue
Low physical activity
Exhaustion
Weakness
Unintentional weight loss
Slowness in walking speed
59
Risk factors for a fall
- +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
Tests for falls
Turn 180 test
Timed up and go test more than 12 seconds
61
What is breakthrough pain?
Transient increase in pain intensity over and above background pain - rapid, severe
## Footnote
i.e a flare up in a chronic condition
62
What are the 2 main subtypes o fpain
* Nociceptive - somatic, visceral (organs)
* Neuropathic - nerves
63
What is nociceptive pain
Pain which is transmitted by damaged non-neural tissue
64
What is neuropathic pain?
Pain which is transmitted by a damaged nervous system
65
What are the features of neuropathic pain?
* burning
* tingling
* shotting
* electric-shock
* 'vice-like' (tight, like a corset)
66
What is the mechanism of paracetamol?
Inhibits production of CNS prostaglandins
67
What is the mechanism of NSAIDs?
* **Inhibit COX** (main enzyme in synthesis of prostaglandins from arachidonic acid)
* Can be selective (celecoxib) or non-selective (ibuprofen)
68
What should you consider before prescribing paracetamol?
* Liver impairment
* Severe cachexia
69
What should you check before prescribing NSAIDs?
Renal and platelet count
70
What are the contraindications to NSAIDs?
* GI bleeding/ulcer Hx
* Asthma
71
What medications interact with NSAIDs?
## Footnote
increase risk of bleeding
* Warfarin
* Digoxin
* Steroids
72
What should you consider when commencing opioids?
## Footnote
11 things (think pharmaceutical and social Hx)
* 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
Side effects of opioids?
## Footnote
common (4), less frequent (3), rare (3)
Common
* consipation
* nausea
* sedation
* dry mouth
Less frequent
* psychomimetic effects
* confusion
* myoclonus
Rare
* allergy
* respiratory depression
* pruritus
74
What are the indications of patches? (fentanyl/buprenorphine)
* Intolerable SE
* Oral route difficulties: compliance or dysphagia
* Renal impairment
75
Why wouldn't you use a patch in acute or unstable pain?
Takes minimum 3 days to reach analgesic concentrations when increased
76
What are the long term harms of opioids?
* Falls/fractures
* Sensitivity
* Immune system
* Endocrine
* Hyperalgesia
* Dependence
77
What are antidepressants useful in? Give 2 examples
## Footnote
(in terms of pain Mx)
**Neuropathic pain**
* amitriptyline
* duloxetine
78
What are antiepileptics useful in? Give 2 examples
## Footnote
(in terms of pain Mx)
**Neuropathic pain**
* pregabalin
* gabapentin
79
What are antispasmodics useful in? Give 2 examples
## Footnote
(in terms of pain Mx)
**Muscle spasms**
* baclofen
* tizinidine
80
What are steroids useful in? Give an example
## Footnote
(in terms of pain Mx)
**Compression Sx**
* dexamethasone
81
What are benzodiazepines useful in? Give 2 examples
## Footnote
(in terms of pain Mx)
**Spasms**, **?neuropathic pain**
* clonazepam
* diazepam
82
What are local anaesthetics useful in? Give an example
## Footnote
(in terms of pain Mx)
**Focal areas of pain**
* topical lidocaine plasters
83
What are bisphosphonates useful in? Give an example
## Footnote
(in terms of pain Mx)
**Bone pain**
* zolendronic acid
84
What are some common palliative emergencies?
* Febrile neutropenia
* SVCO (superior vena cava obstruction)
* Stridor
* Hypercalcaemia
* Spinal cord compression
85
What is neutropenic sepsis/febrile neutropenia?
Life-threatening complication of **neutropenia** following chemotherapy
86
What are the signs of neutropenic sepsis?
* Clinical sepsis - **temp >38 degrees**
* Clinical infection - **chest**, **urine**, skin, GI
87
How is neutropenic sepsis diagnosed?
* **Clinical sepsis** and/or **pyrexia >38C**
* Neutrophil count **< 0.5**
88
What is the management of neutropenic sepsis?
* **IV access**
* **Broad spec ABx**
* **Fluid resus**
* close observation & Ix (FBC, U&E, LFT, CRP, lactate, cultures)
89
What signs would make you think of superior vena cava?
Lung cancer/tumour involving the R upper lobe or mediastinum
90
What are the symptoms of SVCO?
* Facial swelling, redness
* Periorbital oedema
* Arm swelling
* Breathlessness
* Distended veins on chest
91
How is SVCO diagnosed?
**CT chest**
92
How is SVCO managed?
* ABCs
* High dose steroids - **dexamethasone**
* consider anticoagulation
* stenting
* radiotherapy (or chemo)
93
What signs would make you think of stridor?
* Head and neck tumour
* Lung or upper GI tumour
* usually will hear it straight away
94
What are the signs of stridor?
* Noisy breathing - **on inspiration**
* Harsh breath sounds
* Breathlessness (can be a late sign of decompensation)
95
How is stridor diagnosed?
* Clinically
* Upper airway visualisation
* Upper airway imaging (CT)
96
How is stridor managed?
* ABC: oxygen/heliox
* High dose steroids: dexamethasone
* Urgent ENT/oncology review
* Tracheostomy (new airway)
* Stenting (open airway)
* Radiotherapy
97
What signs make you think of malignant hypercalcaemia?
Cancers which has spread to bone:
* breast
* lung
* kidney
* thyroid
* prostate
98
What are some acute and chronic symptoms of malignant hypercalcaemia?
Acute:
* thirst
* confusion
* constipation
* global deterioration
Chronic:
* Depression
* Abdo pain
* Constipation
* Calculi
99
How is malignant hypercalcaemia diagnosed?
**Blood test**
* corrected calcium > 2.6 = abnormal
* corrected calcium >2.8 = usually symptomatic
100
How is malignant hypercalcaemia managed?
* **IV fluids** - immediate priority (lowers serum calcium)
* **IV bisphosphonate** (returns calcium to bone)
* If resistant to bisphosphonate --> **denosumab**
101
What signs make you think of malignant spinal cord compression?
* Cancer which has spread to bone - breast, lung, kidney, thyroid, prostate
* Primary lesions affecting spine (much less common)
102
What are some signs of malignant spinal cord compression?
## Footnote
depends on level, but generally...
* Parasthesia/sensory loss
* Weakness/functional loss
* Cauda equina syndrome
* Loss of bladder/bowel function
* Back pain
* can be non-specific
103
How is malignant spinal cord compression diagnosed?
**MRI spine** - GS
* if can't have MRI, then CT +/- myelography
104
What is the management of malignant spinal cord compression?
* High dose steroids - **dexamethasone**
* Radiotherapy
* Surgery
105
How should a massive haemorrhage be managed in a palliative patient?
* Stop anticoagulation
* Dark towels
* Remain with patient
* Midazolam 10mg stat
106
What are the signs of opioid overdose in a palliative patient?
Toxicity:
* reduced level of consciousness
* reduced resp rate/SpO2
* Myoclonic jerks
* Pinpoint pupils
SE:
* confusion
* hallucinations
* N+V
* constipation
107
How is opioid overdose managed in a palliative patient?
* **Naloxone** - dilute 400mcg in 10ml N saline and give 20mcg every 2 mins until resp function/conscious level improves
* Close observation
108
Why wouldn't you give naloxone to a dying patient?
Can precipitate sudden increase in pain
109
When is 'end of life' care?
Last 12 months of life
