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Phase 3a Finals > Geratology > Flashcards

Geratology Flashcards

1
Q

what is squamous cell carcinoma

rf

A

skin cancer.

metastases rare

smoking
long standing leg ulcers - marjolins ulcer

genetic conditions: xeroderma pigmentosum, oculocutaneous albinism

immunosuppression : following renal transplant, hiv

actinic keratoses and bowens disease

excessive exposure to sun/psoralen uva therapy

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2
Q

features of squamous cell carcinoma

A

on sun exposed sites like head and neck or dorsum of hands and arms

rapidly expanding painless ulcerate nodules

cauliflower like appearance

poss areas of bleeding

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3
Q

how to tx squamous cell carcinoma

A

surgical excision - 4mm if lesion under 20mm in diameter

if over 20 mm then margins should be 6 mm.

MOHS micrographic surgery.

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4
Q

prognosis of squamous cell carcinoma

A

good if well differentiate under 200mm and less than 2mm deep.

poor if poorly diff, over 20mm and 4mm deep and immunosuppressed

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5
Q

frailty means?

A

diminished strength
endurance
physiological function.

physical frailty
frailty phenotype

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6
Q

assessments for frailty

mx

A

fried frailty index

groningen frailty indicator .

mx : multi-component intervention like exercise, nutrition, med review

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7
Q

rf for falling in elderly

A

lower limb muscle weakness

vision problem
balance or gait disturbance - dm, ra, parkinson

polypharmacy

incontinence
over 65
fear of falling
depression
postural hypotension
arthritis in lower limb
psychoactive drug
cognitive impairement

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8
Q

name some qus to ask fall pt

A

where they fell when they fell

anyone see it
why they think they did
have they before
system review
pmh
social hx

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9
Q

meds that can cause postural hypotension

A

nitrates
diuretics
anticholinergic meds
antidepressant
beta blockers
l dopa
acei

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10
Q

meds associated with falls in elderly

A

benzodiazepines
antipsychotics
opiates
anticonvulsants
codeine
digoxin
other sedative agents

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11
Q

what ix would you do in falls

A

bedside tests: basic obs, bp, bg, urine dip and ecg

bloods: fbc u+e, lft, bone profile

imaging: cxr vt head cardiac echo

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12
Q

when would you do mdt assessment for fall pt?

A

over 65 with
over 2 falls in last 12 months

requires med tx

poor performance to complete turn 180 test or timed up and go test.

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13
Q

What is benign paroxysmal positional vertigo?

average age onset

A

mc cause of vertigo encountered

sudden onset dizziness and vertigo triggered by head position change.

55 average. less common in younger pts

peripheral cause of vertigo: issue in inner ear rather than brain.

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14
Q

features of benign paroxysmal positional vertigo?

A

vertigo triggered by change in head position - rolling over bed or gazing upwards

nausea

each episode : 10-20 seconds

positive dix-hallpike manoeuvre

no hearing loss/tinnitus.

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15
Q

what is the dix hallpike manoeuvre?

A

patient sits upright on a examination couch head turned 45 degrees.
support pt head to stay in 45 degree but rapidly lower pt back until head hanging off end of couch 20-30 degrees
hold pt head still turned 45 degree to 1 side and extended 20-30 degrees below level of couch.

watch eyes for 30-60 seconds - look for nystagmus.
repeat test with head turned other way in other direction.

will trigger other sx of vertigo.

rotational beats of nystagmus towards affected ear. (clockwise with left ear and anti for right) (ROTARY NYSTAGMUS)

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16
Q

how to get symptomatic relief from bppv?

A

epley manoeuvre

vestibular rehab - brandt-daroff exercises

betahistine - limited value

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17
Q

recurrence of bppv

A

sx 3-5 yrs after diagnosis

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18
Q

what is the epley manoeuvre?

A

used to tx bppv.
move crystals in semicircular canal into a position that dont disrupt endolymph flow.

do dix-hallpike : pt upright head rotated 45 to lying position, head extended off bed. rotate pts head 90 degrees past central position.
get pt to roll onto side so head rotates further 90 degrees in same direction.
get pt sit up sideways with legs off side of couch.

position head in central position with neck flexed 45 degrees, with chin towards the chest.

at each stage, support pts head in place for 30 seconds and wait for any nystagmus or dizziness to settle.

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19
Q

what are brandt-daroff exercises?

A

do at home to improve sx of bppv .

sit on end of bed lie sideways, from 1 side to other, while rotating the head slightly to face the ceiling.

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20
Q

What is a TIA?

A

brief period of neurological deficit due to vascular cause - last less than 1 hr.

transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction.

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21
Q

clinical features of tia

A

similar to stroke : sudden onset, focal neurological deficit. but dont persist. typically resolve within 1 hr

features:
- unilateral weakness or sensory loss
-aphasia or dysarthria
-ataxia, vertigo, loss of balance
- visual problems: sudden transient loss of vision in 1 eye (amaurosis fugax), diplopia, homonymous hemianopia

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22
Q

typical tia mimics that need excluding

A

hypoglycaemia

intracranial haemorrhage - if on anticoagulant or with similar rf admit for urgent imagine to exclude haemorrhage.

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23
Q

pt with acute focal neuroloigcal sx that resolve completely within 24 hrs of onset. what should i do?

A

give aspirin 300mg immediately

assess urgently with 24 hrs by stroke specialist

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24
Q

imaging for tia

A

ct only when clinical suspicion of an alternative diagnosis that ct can detect - ie haemorrhage concern

MRI - diffusion weight and blood-sensitive - determine territory of ischaemia, detect haemorrhage or alternative pathology - do same day

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25
Q

how would you manage tia?

A

Medication:
- antiplatelet therapy - as long as no CI or high risk of bleeding

  • within 24 hours of onset:
  • clopidogrel - initial 300mg then 75mg od + aspirin initial dose 300mg then 75mg od for 21 days - followed by monotherapy with clopidogrel 75mg od

if not appropriate for dapt:
- clopidogrel 300mg loading dose then 75mg od

ppi considered for dapt.

lipid modification: high intensity statin like atorvastatin 20-80mg daily - reduce non-hdl cholestrol by over 40%

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26
Q

if a patient has af and just had a tia what should happen?

A

give anticoagulation as soon as intracranial haemorrhage excluded

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27
Q

carotid imaging for tia

benefit
what might you find
what would you do ?

A

atherosclerosis in carotid artery might be emboli source in some pts.

carotid duplex ultrasound or ct angiography/mr angiography.

carotid endarterectomy - if pt suffered stroke/tia in carotid territory and isnt severely disabled.

if stenosis over 50%

perform asap within 7 days

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28
Q

urinary incontinence risk factors

A

elderly female
advancing age
previous pregnancy and childbirth
high bmi
hysterectomy
fhx

postmenopause
pelvic organ prolapse
pelvic floor surgery
ms - neuro conditions
cognitive impairement and dementia

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29
Q

classifications of urinary incontinence

A

overactive bladder/urge : detrusor activity - urge to urinate quickly then uncontrollable leakage range from few drops to complete empty.

stress incontinence: cough or laugh small leak

mixed: urge and stress

overflow: bladder outlet obstruction like prostate enlargement

functional incontinence: comorbid physical condition. dementia,sedative meds, injury/illness

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30
Q

stress incontinence happens due to weakness of what?

A

pelvic floor and sphincter muscles - urine can leak at times of increased pressure on bladder

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31
Q

overflow incontinence happens when

what testing to do

A

chronic urinary retention due to obstruction to outflow of urine.

anticholinergic meds
fibroids
pelvic tumours
neuro conditions: ms, diabetic neuropathy, spinal cord injuries.

do urodynamic testing

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32
Q

assessing for urinary incontinence

A

take history.
assess lifestyle: caffeine,alcohol, meds, bmi

severity: frequency of urination/incontinence, nighttime urination, pads and clothing changes

assess pelvic tone and examine to pelvic organ prolapse,atrophic vaginitis, urethral diverticulum, pelvic masses

ask for pt to cough – watch for leakage from urethra

strength of pelvic muscle contraction assessed during bimanual examination - ask women to squeeze against examining fingers.

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33
Q

when i measure strength of pelvic muscle contractions, i do what exam , how do i do it and how is it graded?

A

bimanual exam
woman squeeze against examining fingers.

modified oxford grading:
0 - no contraction
1 - faint
2 - weak
3 - moderate with some resistance
4 - good contraction with resistance
5 - strong contraction, firm squeeze, draw inwards

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34
Q

ix for urinary incontinence

A

bladder diaries - min 3 days
vaginal exam: exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (kegel)

urine dip and culture
urodynamic studies

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35
Q

what are urodynamic studies?

rules

A

measure urge incontinence not responding to 1st line medical tx, difficulties urinating, urinary retention, previous surgery or unclear diagnosis.

pts stop taking anticholinergic and bladder related meds 5 days before test.

thin catheter into bladder and another into rectum. measure pressure in bladder and rectum and compare. bladder fill with liquid then measure:

  • cystometry - destrusor muscle contraction and pressure
  • uroflowmetry - flow rate measured
    -leak point pressure- what point bladder pressure means leakage of urinel. get pt to cough move or jump when bladder filled to diff levels. stress incontinence

-post void residual bladder vol - incomplete emptying of bladder testing

-video urodynamic testing- fill bladder with contrast. take x ray image as bladder emptied.

36
Q

how would you manage stress predominant urinary incontinence?

A

pelvic floor muscle training - min 8 contractions 3 times per day for min 3 months.

surgery: retropubic mid-urethral tape procedures

duloxetine - if women declines surgery : combined noradrenaline and serotonin reuptake inhibitor.

weight loss avoid caffeine diuretics or overfilling bladder or fluid intake.

37
Q

what is duloxetine
moa

A

SNRI antidepressant

combined noradrenaline and serotonin reuptake inhibitor

increased synaptic conc of noradrenaline and serotonin within pudendal nerve = increased stimulation of urethral striated muscles within sphincter = enhanced contraction.

38
Q

how would you manage urge predominant incontinence?

A

bladder retraining - lasts for min 6 weeks - increase gradually intervals between voiding

bladder stabilising drugs: antimuscarinics - 1st line : oxybutinin , tolterodine (both immediate release) or darifenacin (once daily prep)
immediate release oxybutynin avoid in fraily older woman

mirabegron - beta 3 agonist - anticholinergci se in fraily elderly patients

botulinum toxin type a - injection to bladder wall
urinary diversion - redirect urinary flow to urostomy on abdo
augmentation cystoplasty - bowel tissue to enlarge bladder
percutaneous sacral nerve stimulation - implant device in back that stimulates sacral nerves.

39
Q

what anticholinergic side effects will mirabegron give in frail elderly patients?

who is it cid in

how does it work?

A

cognitive decline
memory problems
worsening dementia.

used as alternative for urge iwth less anticholinergic burden.

uncontrolled htn - cid;

beta 3 agonist - stimulatres sns = raised bp. = hypertensive crisis = increased tia/stroke risk.

40
Q

surgical options for stress incontinence

A

tension free vaginal tape - mesh sling looped under urethra and up behind pubic symphysis to abdo wall. - supports urethra reducing stress incontinence.

colpsuspension - stitches connect to anterior vaginal wall and pubic symphysis around urethra- pull vaginal wall forwards adding support to urethra.

intramural urethral bulking - involves injections around urethra to reduce diameter and add support.

autologous sling procedure - similar to tfvt - strip of fascia from pt abdo wall used not tape.

41
Q

what to do if stress incontinence caused by neuro disorder or other surgical methods have failed in tx

A

create artificial urinary sphincter.

pump into labia inflates and deflates cuff around urethra - women control their continence.

42
Q

What are pressure sores?

mc places for them

A

localised injury to skin and underlying tissue caused by prolonged pressure on certain areas of body.

over bony prominences: sacrum, coccyx, heels or hips

43
Q

risk factors for pressure sores

A

immobility: bed rest/wheelchair condition like spinal cord injury,frailty, sedation or coma

nutritional deficiency: malnutrition, dehydration, low protein levels impair skin health and wound healing process

incontinence: urinary/faecal - skin maceration, increase friction between skin and bedding/clothing

sensory perception deficit: limited awareness of pain/discomfort - excess pressure. neuropathies,stroke etc

44
Q

potential underlying causes of pressure sores

A

prolonged pressure - occlusion of capillary blood flow - ischaemia and tissue necrosis.

shearing forces: shear when skin moves 1 way while underlying bone moves opposite direction. damage to bv. and tissues.

foisture: excessive moisture due to perspiration or incontinence. skin vulnerable - damage from friction and maceration.

ageing skin: older skin thinner, less elastic, more fragile. slower cell regeneration.

45
Q

screening for pts at risk of pressure areas

what does it include?

A

waterlow score.

bmi
nutritional status
skin type
mobility
continence

46
Q

grading of pressure ulcers

A

european pressure ulcer advisory panel classification

1 - non-blanchable erythema of intact skinl.l discolouration of skin,warmth,oedema,induraiton or hardness may be used as indicators, in individuals with darker skin.

2 - partial thickness skin loss involving epidermis or dermis, or both. ulcer superficial and presents clinically as abrasion or blister

3 - full thickness skin loss involving damage to or necros of subcutaneous tissue that might extend down to but not through underlying fascia.

4 - extensive destruction, tissue necrosis, damage to muscle bone or supporting structures with/without full thickness skin loss

47
Q

how would you manage pressure sore?

what to avoid?

A

mosit wound environment.
hydrocolloid dressing and hydrogels help.

avoid soap.
avoid drying wound

refer to tissue viability nurse

surgical debridement

wound swab: not routine bc they all usually colonised by bacteria anyway. if abx clinical basis if you see cellulitis.

48
Q

explain non-accidental injury

types of injuries

most severe form : characterised by

how to diagnose

how to manage

A

physical harm/injury intentionally inflicted.

can be child abuse.

fractures
burns
contusions
internal injuries

non-accidental head injury: shaken baby syndrome:
subdural haemorrhages,retinal haemorrhages, encephalopathy.

comprehensive medical evaluation,
radiological ix : skeletal survery, ct/mri.

mdt: social services,paeds,radiology, forensics

49
Q

What is hyperthermia and hypothermia?

hyper: what is it? how can ithappen? what comps?

hypo? what is it? how ? what comps? what can it cause?

A

body temperature dysregulation.

hyper: elevated core body temp. - failed thermoregulation: could be by heat stroke, adverse drug reactions. comps: multi-organ dysfunction if not tx.

hypo: body loses heat faster than it can produce - dangerously low body temp. precipitated by prolonged exposure to cold weather or immersion in cold water. - arrhythmias, impaired conciousness, fatal comps like hypotensive shock

50
Q

mx of hyperthermia and hypothermia

A

underlying cause rectify

stabilist pt core temp

hyper: active cooling techniques and antipyretics

hypo: passive and active rewarming methods. supportive care

51
Q

What is malnutrition?

how does undernutrition manifest?

how does overnutrition manifest?

A

undernutrition and overnutrition.

under: stunting, wasting, deficiencies of micro-macronutrients

over: overweight or obesity.

52
Q

severe form of undernutrition

how does it happen?

what can it lead to ?

A

protein-energy malnutrition.

insufficient intake of protein and energy.

can lead to marasmus, significant weight loss or kwashiorkor with oedema and skin changes.

53
Q

overnutrition leads to the increase risk of what?

undernutrition leads to increased risk of what?

A

noncommunicable diseases like:
t2dm
cv disease
htn
certain cancer.

biochemical abnormalities:
anaemia
hypoalbuminaemia
electrolyte imbalances

54
Q

Aetiology of malnutrition

A

inadequate diet intake
increased nutrient losses or requirements
decreased nutrient absorption
altered metabolic demands.

55
Q

What is constipation?

features

A

functional disorder of the bowel

unsatisfactory defecation because of infrequent stools (<3 times weeklly)

difficult stool passage(with straining or discomfort) or seemingly incomplete defecation.

passage of infrequent hard stools

56
Q

comps of constipation

A

overflow diarhoea
acute urinary retention
haemorrhoids

57
Q

how would you manage constipation?

A

ix and exclude secondary causes, consider red flags

exclude faecal impaction

lifestyle: diet fibre, fluid intake, activity levels

1st laxative: bulk-forming laxative like ispaghula husk

second line: osmotic laxative like macrogol

58
Q

normal times of defaecation in kids

A

mean of 3 times a day for infant under 6 months
once a day after 3 yrs

59
Q

how to make a diagnosis of constipation in children

child under 1 yr

A

2 or more of :

stool pattern :
less than 3 complete stools per week. (type 3/4 on bristol stool form) (doesnt apply to exclusively breastfed after 6 weeks)
-hard large stool
-rabbit droppings) type 1

sx associated with defecation:
-distress on passing stool
-bleeding associated with hard stool
-straining

history:
- previous episodes of constipation
-previous or current anal fissure

60
Q

how would you diagnose constipation of childdren?

child over 1 yrs

A

stool pattern:
-fever than 3 complete stools per week (type 3/4)
- overflow soiling (commonly very loose, very smelly, tool passed without sensation)
-rabbit droppings) type 1
-large infrequent stools that can block toilet

sx associated with defecation
- poor apetite improves with passage of large stool
- waxing and waning of abdo pain with passage of stool
- evidence of retentive posturing: typical straight legged,tiptoed, back arching posture
-straining
-anal pain

history:
- previous ep of constipation
-previous or current anal fissure
-painful bowel movements and bleeding associated with hard stools

61
Q

causes of constipation in children

A

idiopathic

dehydration
low fibre diet
meds: opiates
anal fissue
over-enthusiastic potty training
hypothyroidism
hirschsprungs disease
hypercalcaemia
LD

62
Q

by using the following different sections , i want you to tell me what indicates idiopathic consipation

timing
passage of meconium
stool pattern
growth
neuro/locomotor
abdomen
diet
other

A

timing: starts after few weeks of life. obvious precipitating factors coinciding with start of sx: fissure, change of diet, timing of potty/toilet training or acute events such as infections, moving house, starting nursery/school, fears and phobias, major change in family, taking meds

passage of meconium: under 48 hrs
stool pattern: nil

growth: generally well, weight and height within normal limits, fit and active

neuro/locomotor: no neuro problems in legs, normal locomotor development

abdomen: nil
diet: changes in infant formula, weaning, insufficient fluid intake or poor diet

other: nil

63
Q

by using the following different sections i want you to tell me which indicates “red flag” for underlying disorder

timing
passage of meconium
stool pattern
growth
neuro/locomotor
abdomen
diet
other

A

timing: reported from birth or first few weeks of life

passage of meconium: after 48 hrs
stool pattern: ribbon stools

growth: faltering growth is amber flag

neuro/locomotor: previously unknown or undiagnosed weakness in legs, locomotor delay

abdo: distention
diet: nil
other: amber flag: disclosure or evidence that raises concern of child maltreatment

64
Q

before you tx a child for constipation. you need to assess for whart?

what suggests this

A

faecal impaction

sx of severe constipation
overflow soiling
faecal mass palpable in abdomen - dre only done by specialist.

65
Q
A
65
Q
A
65
Q

if faecal impaction is present, how do you treat constipation in children

A

polyethylene glycol 3350+ electrolytes (movicol paeds plain) - escalating dose regimen: 1st line

add stimulant laxative if movicol doesnt lead to disimpaction after 2 weeks

substitute stimulant laxative single or in combo with osmotic laxative like lactulose if movicol isnt tolerated

inform families that disimpaction tx can initially increase sx of soiling and abdo pain

66
Q

maintenance therapy of constipation in children

A

1st line: movicol
add stimulant laxative if no respoonse
substitute stimulant laxative if movicol not tolerated. add another laxative like lactulose or docusate if stools hard

continue med at maintenance dose for several weeks after regular bowel habit established, then reduce dose gradually

67
Q

general advise for infants not yet weaned under 6 months with constipation

A

bottle fed infants: give extra water in between feeds. try gentle abdo massage and bicycling the infants legs

breast fed infants: unsualy and organic causes consider

68
Q

general advise for constipated children infants that have been weaned or are currently being weaned

A

offer extra water, diluted fruit juice and fruits

if not: add lactulose

69
Q

what is encoperesis?

when is it pathological

sign of what?

what happens

A

faecal incontinence.

not pathological under 4 yrs old.

sign of chronic constipation where rectum is stretched and looses sensation.

large hard stools stay in rectum and only loose stools pass blockage and leak out, cause soiling.

70
Q

rare causes of encoperesis

A

spina bifida
hirschprungs disease
cerebral palsy
ld
psycosocial stress
abuse

71
Q

what is faecal impaction

A

large hard stool blocks the rectum.

72
Q

give me a list of red flags around constipaiton in children

and attach them to the condition

A

not passing meconium within 48 hrs of birth - think cf or hirschprungs

neuro signs or symptoms: in lower limbs - think cerebral palsy or spinal cord lesion

vomiting: intestinal obstruction or hirschsprungs disease

ribbon stool: anal stenosis

abnormal anus: anal stenosis: ibd, sexual abuse

abnormal lower back or buttocks: spina bifidsa, spinal cord lesion or sacral agenesis

failure to thrive: coeliac, hypothyroid, safegaruding

acute severe abdo pain and bloating: obstruction or intussusception

73
Q

when assessing falls patient, you must get lying/standing bp - how to do it and when can you diagnose orthostatic hypotension?

A

measure after 5 mins of lying down, then after 1 minute of standing , then after 3rd minute of standing.

when
1. drop in systolic of 20 more more (with/without sx)
2. drop to below 90 on standing even if drop is less than 20 (with/without sx)
3. drop in diastolic bp of 10 with symptoms

74
Q

most appropriate tool for identifying medications where the risk outweighs the therapeutic benefits in certain conditions?

A

STOPP

75
Q

digoxin toxicity symptoms

A

gi disturbance - nausea vomiting abdo pain
dizziness
confusion
blurry or yellow vision
arrhythmias

76
Q

amitriptyline side effects

A

dry eyes dry mouth hypotension(often postural)
and delirium

constipation
urinary retention
arrhythmias (qt interval prolongation)
hypothermia.

77
Q

what drugs can induce gout?

A

indapamide
thiazide diuretics

78
Q

how should frailty be assessed?

A

PRISMA-7 questionaire

evaluation of gait,speed,self-reported health status

79
Q

things that can cause confusion

A

tsh b12 folate
glucose : hypogly
tfts

80
Q

what is the tool to suggest more medication to give more benefit?

A

START

so for example like ppi for gastroprotection in pts on meds increasing bleeding risk.

81
Q

what type of drug is memantine

A

nmda receptor antagonist

used if first line: donepezil dont work.

82
Q

stopp criteria for warfarin?

A

its an anticoagulant and vit k antagonist.

no proven added benefit when given for longer than 6 months for uncomplicated dvt.

83
Q
A

Phase 3a Finals (25 decks)

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