Family Medicine Shelf Flashcards
Urge Incontinence
detrusor muscle overactivity, involuntary contraction of detrusor muscle and urinary tenesmus (urge to empty bladder).
Anticholinergic agents (oxybutynin) tx
Acute urinary incontinence in Elderly patients management
Presentation :
Acute onset of urinary incontinence, urgency, frequency in an elderly woman
Urinary tract infection is most likely diagnosis common reversible cause of incontinence in elderly
Next Step:
Perform urinalysis and urine culture to rule out UTI
Atypical UTI symptoms in elderly
-Incontinence, urgency, frequency (may lack classic symptoms like dysuria or suprapubic pain)
-If uti is ruled out, consider further tests (e.g., urodynamic studies, cytoscopy)
Stress Urinary Incontinence Management
Presentation :
-Involuntary urine leakage during activities that increase intra-abdominal pressure (e.g., walking, standing, coughing).
-No urgency to urinate before leakage
First-line treatment
-Conservative therapy (Kegel exercises, continence pessary, lifestyle changes (eg, weight loss, alcohol cessation).
-If conservative measures fail, move to surgical options
Next step (after failed conservative treatment):
-Urethral sling surgery: minimally invasive procedure that supports the urethra, preventing leakage during physical activity
Key points:
-Common in postmenopausal women
- Conservative measures first, followed by urethral sling for persistent Stress Urinary Incontinence
Age-Related Macular Degeneration
Presentation
Difficulty reading, requiring bright light, wavy/distorted lines (metamorphopsia) on Amsler grid.
Fundoscopic findings
-Presence of soft drusen (yellow deposits) around macula
-Soft drusen located below the nerve fiber and don’t obscure retinal vessels
Types of AMD
-Dry AMD (nonexudative)
Most common form
Slow progression of central vision
loss
Wet AMD (exudative)
-Less common (10%)
-Faster progression due to retinal neovascularization and hemorrhage
Risk factors
-Age
Most common cause of vision loss in older adults
-Cardiovascular risk factors like HTN and diabetes contribute to the development and progression of AMD.
Key test
-Amsler grid showing central metamorphopsia
Screening for Osteoporosis
Risk factors
-Female sex
-Advanced age (over 65)
-Women under age of 65
Family hx of hip fracture
Excessive alcohol consumption
Smoking
Low BMI
Next step in management
-dual-energy x-ray absorptiometry (DEXA) to screen for osteoporosis
Nutritional Risks in Vegan Diets
Low bone mineral density due to calcium deficiency
Calcium sources
Calcium-fortified foods (soy products), and low-oxalate vegetables (kale, bok choy)
Other common deficiencies
Vitamin B12, vitamin D, iron
-Supplementation or fortified
foods recommended
Normal cognitive Aging
-Mild memory lapses
Forgetting names, losing keys
-Slower processing
-Independence in daily activities is preserved :
Cooking, shopping, socializing
-Differentiate from dementia by assessing impact on daily functioning
Sleep Disturbances in Alzheimer Disease
Common in advanced stages, manifesting as sundowning (nighttime agitation) and daytime sleepiness
First-line management: behavioral interventions like a regular sleep schedule, environmental regulation, and maintaining a familiar routine
Pharmacologic treatments should be reserved for cases where behavioral interventions fail
Management of Alzheimer Disease (AD)
Diagnosis
Progressive memory impairment, disorientation, and incontinence. MRI shows cerebral atrophy
MMSE: score of 19/30 indicates mild to moderate AD
First-line pharmacotherapy:
Acetylcholinesterase inhibitors (e.g. donepezil)
Memantine
-Add for moderate to severe AD or progression despite acetylcholinesterase inhibitors
Creutzfeldt-Jakob Disease
Recognizing CJD
Rapidly progressive Dementia:
-Symptoms develop and worsen over a short period, typically within few months
Characteristic Symptoms:
-Myoclonus: Spontaneous muscle jerking often triggered by external stimuli like loud noises
-Cognitive Decline and Mutism: Patients may become verbally unresponsive while remaining alert
-Blunted Affect: Patients show reduced emotional responses
Key Clues in Physical Exam and History
-Diffuse Myoclonus
-Lack of communicative responses despite being alert
Electroencephalogram (EEG) Findings in CJD
-Characteristic EEG pattern: Triphasic periodic sharp-wave complexes
Prognosis and course of CJD:
-Rapid progression to death: the typical course leads to death within 12 months of symptoms onset
No cure available: management focuses on supportive care
Pathophysiology of CJD
-Prion Disease: caused by abnormal prion proteins leading to spongiform changes in the brain, resulting in rapid neurodegeneration
Transmission Risk: typically sporadic, though familial and iatrogenic cases occur
Frontotemporal Dementia
Key features: personality changes, disinhibition, apathy, and binge-eating
Memory: generally intact in the early stages (MMSE score near normal).
Diagnosis: Clinical, confirmed by neuroimaging (frontal/temporal atrophy).
Prognosis: Rapid progression; average survival of 6 years after onset.
Diagnosis of Alzheimer Disease
Key features: progressive memory loss, word-finding difficulties, spatial disorientation (ex getting lost outside) , and impaired activities of daily living (eg, leaving the oven on).
Cognitive testing: poor performance on serial sevens and clock-drawing test
Physical findings: MRI findings: Generalized cerebral atrophy, especially in the temporal and parietal lobes Temporal lobe degeneration- memory loss; Parietal lobe degeneration- spatial navigation problems
Management of Agitation and Sleep Disturbances in Alzheimer Disease
Behavioral and environmental regulation, first line before pharm drugs :
-Adhering to regular sleep schedule
-Maintaining familiar environment
-Removing ambient noise
Management of Alzheimer Disease
Clinical scenario overview
Patient profile: 78 year old man with gradual cognitive decline over the past year
Symptoms:
Memory impairment: frequently misplaces car keys, forgets long-known neighbors’ names, difficulty recalling address and phone number
Behavioral Changes: More withdrawn, wandering episodes
Functional Decline: Episode of urinary and fecal incontinence
Physical Findings
- Recognizing Alzheimer Disease (AD)
Insidious onset: gradual progression of forgetfullness, disorientation, and functional decline (e.g. wandering, incontinence)
MMSE Score Interpretation:
Mild to moderate AD: MMSE score of 19/30
Moderate to severe AD: <= 18/30
First-line pharmacotherapy: Acetylcholinesterase inhibitors
Donepezil
Rivastigmine
Galantamine
Multiple System Atrophy (MSA)
Parkinson-Plus syndrome: MSA is part of group of disorders known as parkinson-plus syndromes, which share features of parkinson disease but include additional symptoms.
Characterization:
Motor abnormalities
-Tremor and rigidity
Autonomic dysfunction
-Orthostatic hypotension
-Urinary incontinence
Cerebellar symptoms
-Dysdiadochokinesia
-Gait disturbances
-Dysarthria
Poor response to levodopa
-Finding that differentiates Parkinson-plus syndrome from classic Parkinson Disease
Parkinson Disease
Clinical features of Parkinson Disease (PD)
Asymmetrical resting tremor
-A hallmark feature, often unilateral in early stages and improves with voluntary movement
Bradykinesia
-Definition: slowness and reduced amplitude of repetitive movements, such as foot tapping, hand opening/closing, or thunb-to-finger tapping.
-Importance: diagnosis of PD requires presence of bradykinesia along with either tremor or rigidity
Rigidity
-reported stiffness in the limbs
Hypomimia
-reduced facial expression or blank stare
Gait and posture
-assess for shuffling gait and postural instability
Association with REM Sleep Behavior Disorder
-Be aware that this sleep disturbance is common in PD and can precede motor symptoms
Pathophysiology of Parkinson Disease
-Degeneration of dopaminergic neurons
-Occurs in substantia nigra
-Leads to decreased dopamine levels in striatum
-Effect on motor cortex
-Dopamine deficiency results in decreased excitatory signaling to the motor cortex, causing bradykinesia and rigidity
Normal Pressure Hydrocephalus
Triad :
Urinary Incontinence (Wet)
-Characterized by urge incontinence due to loss of central inhibition of the detrusor muscle
Cognitive Deline (Wacky)
-Presents as confusion, memory deficits, and overall cognitive impairment
Gait Abnormalities (Wobbly)
-Described as a wide-based, short-stepped gait.
Pathophysiology
-NPH results from compression of periventricular white matter tracts
-Affecting urinary control and motor functions
Differentiate Urge Incontinence in NPH
-Recognize that NPH-related incontinence is due to central loss of inhibition rather than bladder or sphincter dysfunction alone
Imaging
-Dx confirmed by brain imaging showing ventriculomegaly without cortical atrophy
Spikes protocol for delivering bad news to patient:
1.S-setting up interview
-Arrange privacy and manage time to avoid interruptions
-Offer to involve friend or family member
-Mentally rehearse and review clinical information
-Establish rapport by sitting down with patient
- P- perception
-Assess patient’s understanding of their situation
-Example: “what have you been told about your tests so far?”
I- Invitation
-Ask the patient how much detail they want to hear
-Example: “would you like me to explain everything in detail or focus on the next steps?:
- K-Knowledge
-Deliver the information gradually and clearly
-Use simple language and check the patient’s understanding frequently
5- E- Emotions and empathy
-Recognize and respond to the patient’s emotions with empathy
-Example” I can see this is very difficult. How are you holding up?”
6 S- strategy and summary
-Summarize the diagnosis and treatment options
-Provide a plan and ensure the patient knows what to expect next
Managing severe pain for terminally ill patient in hospice care
-Prioritize pain relief and quality of life in hospice care
-Gradual titration (e.g. by 50% every 24 hours) helps minimize risk of respiratory depression
-Principle of double effect supports using higher doses for pain relief, even if it may slightly hasten death
-Reassure family members about the goal of ensuring the patient’s comfort and dignity.
Eligibility for hospice care
-Must have life expectancy of less than 6 months
-Must forgo therapies intended to prolong life, but palliative treatments (e.g., radiation for symptom relief) are allowed.
Indications for select preoperative tests
ECG
-Hx of coronary artery disease or arrhythmia
-Asymptomatic patients w/ risk of MACE (major adverse cardiovascular event) >- 1%
Chest Radiograph
-Hx of cardiopulmonary disease
-Undergoing upper abdominal/thoracic surgery
Hemoglobin
-Hx of anemia, significant expected blood loss
-Undergoing major surgery
Coagulation and platelets
-Hx of abnormal bleeding, anticoagulant use
-Liver disease, malignancy, planned spinal anesthesia
Creatinine and electrolytes
-History of kidney disease, cardiovascular risk calculation
-Predisposing medications (eg, diuretic, ACE inhibitor, ARB)
