General Med/Geriatrics Flashcards
Definition of postural (orthostatic) hypotension
Systolic drop of at least 20 mmHg or a diastolic drop of at least 10 mmHg when going from sitting/lying to standing after 3 minutes of standing
Treatment options for orthostatic hypotension
Midodrine and Fludrocortisone
Factors favouring a non-epileptic attack (pseudoseizure) vs syncope or epilepsy
Gradual onset but sudden drop to floor
Arms flexing and extending, pelvic thrusting
Prolonged seizures (often >30 minutes)
Symptoms wax and wane
Much more common in females
Crying after seizure
2 factors favouring true epileptic seizures vs pseudoseizures
Tongue biting
Raised serum prolactin
Aortic dissection definition
Tear in the tunica intima of the wall of the aorta
Single biggest risk factor for aortic dissection
Hypertension
Associative symptoms of type A aortic dissection vs type B aortic dissection
Type A (originates in ascending aorta): chest pain
Type B (descending aorta): upper back pain
Type of chest/back pain felt in aortic dissection
Typically severe and ‘sharp, ‘tearing’ in nature’
Maximal at onset (DDx from myocardial infarction which has a build in intensity)
Pulse featured changes in aortic dissection (2)
- weak or absent carotid, brachial or femoral pulse
- variation (> 20) in systolic BP between arms
Aortic dissection investigations
Chest X-ray: widened mediastinum
CT angiography (gold-standard): false lumen
TOE: useful in unstable patients
Risk factors for DVT / PE
Immobility
Recent surgery
Long-haul travel
Pregnancy
Hormone therapy with oestrogen (COC / HRT)
Malignancy
VTE prophylaxis options and contraindications
- LMWH e.g. enoxaparin / deltaparin
- contraindications: warfarin / DOAC - Anti-embolic compression stockings
- contraindications: PAD
Provoked: 3 months
Unprovoked: 6 months
Scoring system used to assess risk of PE
Wells score (risk factors e.g. recent surgery and clinical findings e.g. HR above 100 + haemoptysis)
4 symptoms of pulmonary embolism
SOB
Cough
Haemoptysis
Pleuritic chest pain
ABG results of pulmonary embolism
Respiratory alkalosis: low O2 causes raised respiratory rate which blows off extra CO2 = alkalosis / type 1 respiratory failure
Outcome of Wells score/Management of PE
Likely: perform CT pulmonary angiogram
Unlikely: perform a d-dimmer and if positive perform CTPA
Clinical signs PE
Tachycardia + tachypnoea with clear chest
1st line treatment PE with haemodynamic instability
Thrombolysis
2 most common causes of pericarditis
Idiopathic
Viral infection (HIV, CSV, EBV)
2 key presenting features of pericarditis
Pleuritic chest pain (often relieved by sitting forwards)
Low grade fever
Key auscultation finding in pericarditis
Pericardial friction rub (rubbing, scratching sound)
Investigation findings in pericarditis (bloods, ecg, echo)
Blood tests: raised inflammatory markers (WCC, CRP, ESR)
ECG: saddle-shaped ST-elevation, PR depression
Echo: can be used to diagnose pericardial effusion
Management of pericarditis
1st line: NSAIDs (aspirin or ibuprofen)
+ Colchicine (taken longer term to reduce risk of recurrence or symptoms beyond 14 days)
Treatment of paracetamol overdose and MOA
N-acetylcystine replenishes glutathione stores so that NAPQI can be converted to a less toxic product, preventing hepatocyte damage
within 8 hours of ingestion
divided into 3 consecutive IV infusions
Time frame when activated charcoal can be used in paracetamol overdose management
Within 1 hour
Risk factors for hepatotoxicity outcome in paracetamol overdose
Chronic alcohol user
HIV
Anorexia
P450 inducer drugs
Heparin overdose management in cases such as significant haemorrhage
Protamine sulphate
fully effective against unfractionated heparin and partially effective against LMWH
LMWH MOA
Activates antithrombin III which inhibits factor Xa
B12 absorption
Binds to instrinsic factor (secreted from parietal cells in the stomach)
Actively absorbed in the terminal ileum
3 causes of B12 deficiency
Pernicious anaemia (most common cause) - lack of intrinsic factor
Vegan diet
Crohn’s disease: either disease activity or following ileocaecal resection
B12 deficiency causes which type of anaemia
Megaloblastic macrocytic anaemia
Medication given in B12 deficiency
IM hydroxocobalamin
What should be treated first in B12 deficiency with folate deficiency
Treat the B12 deficiency first - giving patients folic acid when they have B12 deficiency can lead to subacute combined degeneration of the cord
SCD of the cord = combined dorsal column and lateral corticospinal tracts affected
Secondary prevention ACS medications
Block An ACS
Beta blocker
ACEi
Aspirin
Clopidogrel
Statin
Site of iron absorption
Duodenum and jejunum
Risk factors for osteoporosis
SHATTERED
Steroids
Hyperthyroidism
Alcohol/smoking
Thin (BMI <22)
Testosterone deficiency (female)
Early menopause
Renal/liver failure
Erosive or inflammatory disease (Rheumatoid arthritis, Ank Spond)
Dietary Ca2+ deficiency / Did mum or Dad have it?
Gold standard investigation for diagnosing osteoporosis
DEXA scan T score of less than -2.5
Osteopenia DEXA results
T score -1 to -2.5
1st line treatment for osteoporosis
Alendronate
Indication for diagnosis of osteoporosis / treatment without a prior DEXA scan
following a fragility fracture in women aged 75 years or older
2nd line treatment for osteoporosis
25% of patients cannot tolerate alendronate due to GI problems
Other bisphosphonates e.g. risedronate or etidronate
Polypharmacy definition
A single patient taking 5 or more medications daily
benign prostatic hyperplasia treatment
Tamsulosin (alpha blocker)
Common side effects = dizziness and sexual dysfunction
How should alendronate be taken
Standing/sitting upright for at least 30 minutes after taking it
Take it 30 mins before breakfast with plenty of water and on an empty stomach
contraindications to joint aspiration in a non-theatre setting
Joint prosthesis
Bacteraemia
Inaccessible joints
Overlying infection in the soft tissue
LFT investigation alcoholic liver disease
AST level higher than ALT liver
S > L (more soda than lime)
Screening test for malnutrition
MUST (malnutrition universal screening tool)
- BMI
- recent weight change
- presence of acute disease
Scoring system for assessing the risk of a patient developing a pressure sore
Waterlow score
- BMI
- nutritional status
- skin type
- mobility
- continence
4 risk factors for developing pressure ulcers
Malnourishment
Incontinence
Lack of mobility
Pain (leads to reduction in mobility)
Falls risk factors
Vision problems
Gait disturbances: diabetes, rheumatoid arthritis, Parkinson’s
Polypharmacy (4+ medications)
Incontinence
> 65
Fear of falling
Depression
Postural hypotension
Cognitive impairment
Medications that cause postural hypotension
just recognise these and associate with falls in elderly
Nitrates
Diuretics
Anticholingeric
Antidepressants
Beta-blockers
L-dopa
ACEi
Medications associated with falls (due to mechanisms other than postural hypotension)
think sedation
Benzodiazepines/Zopiclone
Antipsychotics
Opiates
Anticonvulsants
Codeine
Digoxin
Investigations to consider after a fall
Bedside tests e.g. basic obs, BP, blood glucose, urine dip, ECG
Bloods e.g. FBC, U&E, LFT, bone profile
Imaging e.g. CXR, CT head, echo
2 recommended tests from NICE to assess risk of further falls in elderly who have fallen in the last 12 months
Turn 180
Timed up and Go test
Falls criteria for MDT assessment by qualified clinician in patients over 65
> 2 falls in last 12 months
Fall that requires medical treatment
Poor performance or failure to complete Turn 180 or Timed Up and Go test
Falls individuals who do not meet this criteria should be reviewed annually and given advice
4 management options for falls in the elderly
Strength and balance training (physiotherapist)
Home hazard assessment / assessment to improve independence with ADLS (occupational therapist)
Vision assessment
Med review (pharmacist)
Rhabdomyolysis causes
Seizure
Collapse/coma e.g. elderly patient who has collapsed at home and found hours later
Crush injury
McArdle’s syndrome
Statins (esp if co-prescribed with clarithromycin)
Ecstasy
rhabdomyolysis blood results
Elevated creatinine kinase
Hypocalcaemia (myoglobin binds calcium)
Elevated phosphate (released from myocytes)
Hyperkalaemia (before AKI)
Metabolic acidosis
Management of rhabdomyolysis
IV fluids (to maintain good urine output)
1st line sedative in delirium
Haloperidol or Olanzapine
PD: if antipsychotics required urgently then use quetiapine or clozapine
How should frailty be assessed
- Evaluation of gait speed
- Self-reported health status
- PRISMA-7 questionnaire (age, sex, health problems, assistance required and walking aid use)
4 palliative medications prescribed in end of life care and the symptoms they treat
Pain: morphine
Respiratory secretions: hyoscine bromide
Nausea: haloperidol
Agitation: midazolam
Causes of weight loss and weakness in elderly
Frailty
Aging
COPD
Malignancy
Depression
Osteoporosis scoring system
Fraxx (BMI, smoking, alcohol, previous fracture)
Malnutrition
State in which a deficiency of energy, protein or other nutrients causes measurable effects on outcome
Starvation, sepsis, malabsorption
4 prevention of pressure sores
Barrier creams
Pressure redistribution
Repositioning
Regular skin assessment
Key parts of mental capacity act (5)
Assumed capacity
Maximise decision making capacity
Freedom to make unwise decisions
Best interests
Least restrictive option
