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IPAP > Geriatrics > Flashcards

Geriatrics Flashcards

1
Q

Geriatric clinical approach includes ? three domains that affect ? and ?

What are the 3 main outcome of the assessment for this population

Older PTs care about what 3 results of a prognosis?

A

Function, Social, Psych
Well being/Quality of life

Prognosis
Patient goals
Functional status

Function Independence Dementia

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2
Q

What are the Activities of Daily Living

What are the instrumental activities of daily living?

A

Continence Feed Toilet
Transfer Bathe Dress

Drive Meds Telephone Shop
Misenplace Clean Laundry Finance

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3
Q

How is a Functional Evaluation conducted

What is the leading cause of non-fatal injuries and death in older PTs?

How often is this leading cause assessed?

A

Time to get up from chair
Walk 10ft, return to chair
>30sec= impaired mobility

Falls, Gait

Incidence and Frequency annually

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4
Q

How is gait assessed?

What are the 4 parts of the PTs gait that are assessed?

A

Can PT rise from chair w/out hands- quad strength

Symmetry Length Height
Width

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5
Q

What are the intrinsic RFs for a fall?

What are the secondary RFs

How can their near/far vision and hearing be tested?

A

Meds Vision PHOTN
Atrophy Vit D- 800IU/day

Light Footwear Trip hazard Safety

Near- Jaeger
Far- Snellen
Hearing- whisper test

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6
Q

Define the mini cognition test

What is the next step if they fail this test?

How is depression screened for?

A

3 item recall, clock drawing- 2min
Both norm- dementia unlikely

Mini mental exam- 10min
MOCA, specific- 30min

PHQ 2: two questions, one pos warrants investigation

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7
Q

What are the two questions asked during the PHQ 2 and what are they assessing?

A

Past 2 wks, felt down, depressed, hopeless- depressive mood

Past 2 wks, felt little interest or pleasure doing things- anhedonia

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8
Q

How does the eye and vision change due to increased age?

These changes lead to ? condition

Why do PTs have difficulties w/ reading in dim light

A

Lens becomes less flexible, less accommodation

Presbyopia

Dec light to retina

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9
Q

? is the leading cause of vision impairment in the US/world

What are the typical Sxs of this MC

What will be seen on PE

A

Cataracts

Blurred yellow vision w/ increase sensitivity to glare

Central opacity
Dec red reflex

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10
Q

What is the leading cause of irreversible vision loss in PTs >65y/o

What are the two types and characteristics of each

A

Age related macular degeneration

Non-neovascular, dry (MC):
Gradual central blurring
Difficult reading fine print/street signs, facial recognition
Rx: antioxidants and Zinc

Neovascular, wet:
Rapid central vision loss
Refer for Tx w/ anti-VEGF

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11
Q

How does Diabetic Retinopathy present

How is it managed

What exam is needed annually

A

Blurred vision
Field constriction
Scotoma

Observe w/ referral

Dilated funduscopic exam

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12
Q

What are 4 types of eye complaints that require immediate referral?

Cerumen impaction will present w/ ? PE findings

What age related deterioration is overlooked but a contributor to morbidity

A

Rapid Painful Monocular
Vision loss

Weber to L
Rinne BC>AC on L

Hearing loss

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13
Q

Hearing loss is independently associated w/ ? issues in PTs

What is the MC type of hearing loss

What causes conductive hearing loss in these PTs

A 
Incident dementia
Accelerated cognitive decline
Poor neurocognitive function
Increase falls
Gait disturbance

Sensorineural HL- presbycusis

Perfs Impaction Effusions

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14
Q

What are the Aminoglycoside antibiotics associated w/ hearing loss?

What is the criteria for OHOTN

A

Gentamicin Amikacin Vancomycin Erythromycin Neomycin Streptomycin

SBP dec 20mm
DBP dec 10mm <3min of Sxs

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15
Q

How is cognitive impairment different from normal aging to concerning?

Define Mild Cognitive Impairement

A

Normal aging- PT remembers later w/ intact learning and subtle deficits in memory function w/out functional impairment

Cognitive function below normal for age/education but severe enough for dementia

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16
Q

MCI is characterized by what 3 parameters

A

Subjective complaints validated by second person

Evidence of objective cognitive impairment in one of more domain

Intact functional status

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17
Q

If PT presents w/ memory loss and draws all numbers on one side of a clock, ? is Dx

When does the Dx of Dementia begin and how quickly does the risk increase?

A

Vascular dementia

Starts at 60
Doublex every 5yrs

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18
Q

What are the 5 types of dementia in order of frequency and RFs for each

A

Alzheimer-
RF: Age FamHx

Lewy Body- Parkinsonism Visual hallucinations Cognitive fluctuant

Vascular-
RF: DM Age Smoking HTN Lipidemia

Frontotemporal- Personality/Social behavior changes Nonfluent speech

Neurodegenerative-
Huntingtons Metabolic abnormalities

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19
Q

What are the key features of Dementia

What is focused on during PE

PTs present w/ memory loss, temper change worse at end of day and disagrees w/ caregiver, what assessment is done

A

Gradual, stable onset
ADL interference
Inattention on gradient
Non-reversible cognitive decline

Functional assessment w/ ADL/IADLs
Neuro exam

Mini Mental state exam- 3 item recall, clock test
Both norm= r/o dementia

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20
Q

When/what PT would be considered high risk for dementia

How often are Mini Mental State Exams repeated?

What does this test indicate or suggest for Dx

A

> 80y/o

q6-12mon

Cognitive decline, suggests Dx of MCI, dementia

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21
Q

MOCA test is more influenced by ? and is more ? than MMSE

What general labs are ordered for a Dementia work up

What specific labs would be ordered?

A

Education
Sensitive, particularly for detecting MCI

CBC Chem-18 (Kidney E+ Glucose Liver)

BETCH CDR
B12 ETOH TFTs Ca HIV
CSF Drug/Tox screen RPR

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22
Q

What other Dx co-exists w/ dementia in half of PTs

Why is identifying this co-existing Dx important

How would this underlying issue be suspected

A

Depression

Can be cause of cognitive defecits
Must be ID’d/r/o prior to Dx of dementia

Memory complaints OOP to deficits

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23
Q

Define Delirium

What is the classic triad for Alzeimers

A 
Sensory deficit
Other psych d/0
Delerium
Depression
Alcohol abuse
Meds- BEERS LIST

Memory impairment
Visuospatial problems
Language impairment

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24
Q

Alzheimer

A

Early: retain social function, fail complex tasks

Disorientation:
Time Place Person

Languae:
Anomic Fluent Mutism

Lost in familiar places
Behavior changes common

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25
Q

Lewy Body Dementia

A

2nd MC dementia:

Parkinsonism after/w/ onset
Parkinson dementia is late in dz

Fluctuating cognitive impairment
Visual hallucination- can differ real from fantasy w/out concern

REM sleep d/o and severe sensitivity to antipsychs- suggest LBD

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26
Q

Vascular Dementia

A

Dx base on radiographic evidence of cerebrovascular dz

Sudden onset after stroke/step wise, not continuous

Patchy deficit, not as severe as Alzheimer

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27
Q

Fronto Temporal Dementia

A

Younger onset, 50y/o, Mis-Dx as Pysch d/o

Picks Dz:
Behavior/Personality changes w/ intact memory
Hyperorality
Loss of social awareness, spares visuospatical abilites
Develops new artistic talent

Progressive aphasia
Semantic dementia

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28
Q

What meds are used in Dementia Tx for Cognitive Impairement

A 
Cholinesterase inhibitor, ChEI- 
Galantamine Rivastigmine Donepezil  
Differ in t1/2, titrate x 8-12wks
S/e: GI Syncope Bradycardia
Improved MMSE/MOCA 6-12mon= effective

Memantine- NMDA antagonist
Added to ChEl when dementia reaches moderate severity
S/e: HA

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29
Q

How is Vascular dementia Tx

What non-pharmaceutical Tx can be done for behavior problems

A

Tx RFs for stroke:
Tobacco HLD AFib DM
Permissive HTN- SBP 150+
Consider ChEI (GRD), Memantine

Bright light Music Walk Pets

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30
Q

What meds can be used for Dementia induced behavior problems?

A

SSRI Mood Antipsych stabilizer ChEIs

Olanzapine/Risperidone-
Anti-psych, best effectiveness
BBW: mortality, CV events, Tardive diskinesia in dementia PTs

Citalopram- SSRI

Carbamazepine/Valproic Acid- mood stabilizer

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31
Q

What Tx methods are not recommended for dementia due to lack of efficacy/potential for harm?

What are the criteria for major depression

A

Gingko biloba Estrogen NSAID Vit E

Two weeks w/ at least:
Depressed mood and/or Anhedonia
Plus 3-4: SIGECAPS
Sleep Interest Guilt Energy Concentration Appetite Psychomotor SI

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32
Q

What screening tool is used for detecting depression in in older adults?

What are the DDxs?

A

PHQ-2

Delirium
Cognitive impairment
Chronic medical condition (weak/fatigue)

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33
Q

What meds are used for depression in adults and their s/e

A

SSRIs: Esc/Citalopram Fluoxetine Paroxetine Sertraline
Citalopram: QT prolongation, Torsades- Max 20mg
Fluoxetine: long t1/2, P-450 inhibitor

SNRI: Des/Venlafaxine Duloxetine

TCA: Amitriptyline Imipramine Doxepin
Rarely used in older adults d/t s/es

Mirtazapine- appetite stimulant, insomnia

Buproprion- smoking cessation

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34
Q

What are the risks of SSRIs as a class

What are the risks of TCAs

A 
Seratonin Syndrome 
HTN
HypoNa
Inc bleeding risk w/ anti-coagulants
Fall risk

OD
OHOTN
Arrhythmia
Cognitive impairment

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35
Q

When do depressed PTs need to be referred to Psych

What are three meds that are hydrophilic and would bind to proteins and decrease available amount?

What 3 classes of drugs cause 2/3 of hospital admissions

A

Mania/Psychosis
Failure x 2 meds
Electroconvuslive therapy
RF for SI

TSH Warfarin Phenytoin

Anticoagulant/platelets
Diabetes

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36
Q

What is the two types of Pneumoccoccal vaccine given at 65y/o

When are herpes zoster vaccines given?

What age are cervical screenings stopped

A

PPSV23 and PCV 13

50y/o

65y/o

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37
Q

When are lung CTs needed for smoking PTs

When is osteoporosis screened for ?

How often is hyperlipidemia screened for

A

55-80y/o w/ 30ppy or quit <15yrs

F >65y/o, initial
M >70y/o, consider

Initial, q5yrs

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38
Q

Urgency Incontinence Sxs

Causes

Tx

A

Detrusor over activity- Involuntary loss followed w/ urgency

Stroke
Alzeihmers/Parkinson
BPH w/ overflow

Anticholinergic

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39
Q

Stress urinary incontinence Sxs

Causes

Tx

A

Loss of urine w/ strain/exertion from sphincter failure

Pelvic floor weakness (surgery/birth)
Prostate surgery Hx

Topical estrogen

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40
Q

Mixed urinary incontinence Sxs

Causes

A

Involuntary loss of urine w/ urge and w/ exertion/stress

Combo of urge and stress

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41
Q

Overflow incontinence Sxs

Causes

Tx

A

Weak stream, incomplete emptying

BPH
Impaction/fibroids
Diabetic neuropathy
Pelvic organ prolapse

Alpha adrenergic blockers

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42
Q

PT presents w/ stress urinary incontinence, what test is used to confirm Dx?

What two tests can be ordered for urinary incontinence

A

Bladder stress test

UUI: bladder competence/detrusor over activity
SUI: urethra function, post-void residual

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43
Q

How do anticholinergics contribute to urinary incontinence?

How do diuretics contribute to urinary incontinence?

How do opioids contribute to urinary incontinence?

A

Affect bladder wall/sphincter

Inc volume/diuresis

Receptor induced dysfunction

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44
Q

How do A-adrenergic agonists contribute to urinary incontinence?

How do A-adrenergic antagonists contribute to urinary incontinence?

How do CCBs contribute to urinary incontinence?

A

Urethral sphincter constriction

Urethral sphincter relaxation

Dec smooth muscle contractility

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45
Q

How is stress incontinence Tx

How is Urge incontinence Tx

How is overflow Tx

A

Kegels/Pessaries
Estrogen
Surgery

Estrogen
Antimuscarinic- Oxybutynin
B-agonists- Mirabegron

Alpha blocker- Doxazosin
5a inhibitors- Finasteride
Cath/Surgery

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46
Q

Define Scoliosis

Define Kyphosis

Define Lordosis

A

Spine is C or S shaped

Thoracic spine curves out

Lumbar spine curves inward

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47
Q

How does OA present

What will be seen on PE

What would be seen on x-rays

A

Mechanical pain worse w/ activity, better w/ rest

Joint line tenderness w/ bone enlargements

Narrowing, osteophytes, sclerosis and cysts

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48
Q

What meds are used for OA Tx

Where are fragility Fxs due to osteoporosis likely to occur

What algorithm is used to calculate a PTs 10yr Fx risk

A

Acetaminophen- initial choice
NSAIDs- acetaminophen failure
Tramadol

Hip Vertebrae Wrist

FRAX

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49
Q

What are the three classifications of osteoporosis

A

Type 1: post-menopause loss of estrogen

Type 2: >75y/o, loss of Zinc, lack of Ca intake

Secondary: chronic dz or medication induced (GCSS); equal in M-F

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50
Q

What DEXA measurements correlate to normal and osteoporosis

When are DEXA scans recommended

A

Normal: -1.0 or more
Penia: -1.0 - -2.5
Porosis: -2.5 or less
Severe/established: -2.5 or lower and fragility Fx

65y/o or older

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51
Q

What meds are given for Osteopenia

What DEXA score is osteopenia but is changed to porosis based on criteria

A

Ca/Vit D 1000/800 w/ weight bearing exercises

Penia w/ FRAX 10yr probability of hip Fx 3% or more or,
10yr probability of other major porosis Fxs 20% or more

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52
Q

What lab tests are ordered for Secondary causes of osteoporosis

A

Hypogonad- T, Prl

Primary HyperPara- PTH

Secondary HyperPara- 25 Hydroxy Bit D, PTH

Multiple myeloma- eletrophoresis, free light chains

HyerThyroid- TSH

Malabsorption- transglutaminase Ab

Hypercortisolism- urine cortisol

Mastocytosis- tryptase, urine N-methylhistidine

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53
Q

What meds are first line Tx for Osteoporosis

What selective estrogen receptor modulator may be sued

A

Bisphosphonates-
AIR-onate
Zoledronic acid

Raloxifene

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54
Q

Delirium

A

Abrupt onset that fluctuates over hrs-wks

Impaired attention, alertness, orientation

Disrupted sleep-wake cycle

Agitated/withdrawn

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55
Q

Dementia

A

Insidious onset w/ slow decline over mon-yrs

Attention intact early, impaired later in dz

Normal sleep, alertness

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56
Q

What is pathognemonic for delirium

What other key features may be seen

A

Acute change in baseline mental status over hrs/days

Fluctuating
Rambling 
Alerted LoC
Inattention
Disorganized thinking
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57
Q

What is the leading precipitating factor to delirium

What are examples of this leading cause

A

Medications

Sedative hypnotics
Opiates
Anticholinergics
Polypharm
Benzos
ETOH
TCAs
CCS
H2 receptor antagonists
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58
Q

? may be the first sign of serious underlying dz

What must be carefully r/o

A

Delirium

Occult infection

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59
Q

Define the Confusion Assessment Method

What are two features not seen in mild/mod dementia

Worsening confusion above baseline cognitive impairment suggests ? Dx

A

Acute onset, fluctuating and,
Inattention and
Disorganized thought or Altered LoC

Inattention
Altered LoC

Delirium

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60
Q

What are the steps of delirium Tx

What meds are last line choices for Tx

What needs to be avoided

A

ID/Tx underlying cause
Eradicate contributing factors
Manage Sxs

Risperidone Olanzapine Benzos
Haldol Quetiapine

Restraints

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61
Q

What are the 4 characteristics of Parkinsons

What causes these Sxs

What is the name of the gait they adopt

A

Bradykinesia
Muscle rigidity- cog wheel
Posture instability- late
Resting tremor- pill rolling

Loss of substantia nigra and depletion of dopamine

Festinating

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62
Q

? is the second MC degenerative neuro d/o after Alzheimer

With an onset between 60-65, if a PT present older than ?, Dx is usually primary or secondary

What is a required feature for Dx

A

Parkinsons

> 75

Bradykinesia plus 1 Sx

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63
Q

? is the MC cause of Parkinson’s

What presentations are red flags for secondary causes

What is the strongest alerting factor

A

Idiopathic

Symmetric
Lack of tremor
Atypical features

Lack of response to high dose of dopamine/Levodopa

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64
Q

What are two classes of drugs that can induce Parkinsons

Define Parkinson Plus Syndrome

What are the first and second line meds for depression in Parkinson PTs

A

Antiemetic/psychotic

Atypical Parkinsons- associated w/ disabling features (autonomic failure, early fall/dementia)

1: SSRI, 2: SNRI

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65
Q

Parkinson PTs may need to have ? meds d/c as Dz progresses

What medication may be added for PTs that develop dystonia/involuntary movements while on carbi/levodopa

A

Anti-HTN

Pramipexole- dopamine agonist
S/e: drowsy hallucinations risk-taking behavior

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66
Q

? is the DOC for Parkinson PTs >70y/o and <70y/o

Above is the DOC because ? meds work poorly in these age groups?

What enzyme converts Levodopa into Dopamine

A

> 70:Levodopa
<70: Pramipexole, Ropinirole

Pramipexole
Amantadine
Ropinirole
Anticholinergics

DOPA-decarboxylase

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67
Q

What features of Parkinson respond less to Levodopa than other Sxs

What PT education has to occur w/ these meds

MOA of Carbidopa

A

Axial- speech/gait

30min before meal

Decarboxylase inhibitor, prevents peripheral Levodopa to dopamine

68
Q

What are the 3 types of Tremors, PE findings and causes

A

Resting: tremor at rest, associated w/ hypokinesia or rigidity; Parkinsons

Intention: tremor during movement, increases near target, nothing at rest; cerebellar dz, MS, chronic ETOH use

Postural: tremor w/ sustained posture of extremity; Wilson’s Dz

69
Q

What medication can be added for PTs presenting w/ essential tremors

How do these present

What are the first and second line Txs

A

Propranolol
S/e- HOTN Brady Broncho constriction

Forearm, head, voice, trunk bilateral, postural-kinetic

1st: Primidone
Occupational therapy
Propranolol
2nd: Gabapentin/Topiramate
Unilateral thalamotomy
70
Q

How do strokes present

What are the two categories

What are the 3 parts of the Cincinnati stroke scale

A

Neuro deficit or HA of abrupt onset

Ischemic
Hemorrhagic: Intracerebral, SubArachnoid

Facial droop
Arm drift
Speech

71
Q

What are the two phases of Cerebrovascular Dz diagnostics

What are the Ischemic Stroke Sub-types

A

Acute triage: Labs, Rads
Investigation after Dx of Stroke is established

Large artery atherosclerosis- carotid, stenosis
Cardioembolism- AFib
Small vessel occlusion- lacunar stroke
Stroke, other- arterial dissection
Stroke, undetermined- cryptogenic
72
Q

What is the underlying etiology for intracerebral hemorrhages

Inclusion criteria for administering tPA for ischemic strokes

A

HTN
Cerebral amyloid angiopathy
Anti-coagulation related hemorrhage

Sx onset <4.5hrs
18y/o or older
Dx of ischemic stroke causing neuro deficits

73
Q

What are the considerations for pushing tPA in acute ischemic strokes

What are the antiplatelet agents first chosen for non-cardioembolic CVDz

A

3hrs of Sx onset
Extended to 4.5hrs if <80y/o
BP <185/110

ASA
Clopidogrel
Dipyridamole and ASA

74
Q

What meds are used as anticoagulants in AFIB

What is the name of the procedure to open the carotid artery when more than ? is stenosed

Define TIA

A

Warfarin
DOACs- Rivaroxoban Apixaban Dabigatran

Carotid Endartectomy >50% stenosis

Transient episode of neuro dysfunction (Sxs <1hr) from focal brain/spine/retinal ischemia w/out infarct

75
Q

What are the 3 main mechanisms of TIAs

How does Takotsubo Cardiomyopathy present

A

Embolic- extra cranial artery, heart, aorta
Lacunar/small vessel- stenosis of intracerebral vessel
Low-Flat TIA- atherosclerosis of internal carotid

STEMI mimickery
No artery occlusion
F>M

76
Q

What would be seen on imaging of a Takotsubo PT

What meds are used for chronic/long term therapy in coronary artery Dz PTs

A

Octopus pot- apical ventricle ballooning

Statin
Anti-platelet
BBs
ACE/ARB if HFrEF

77
Q

What medication is used to Tx dilated cardiomyopathy

What meds are used for different types of HF

A

BB- Bisoprodol

HFrEF >50: control HTN, Na intake, daily weight, Loops
HFrEF <40: BB and Sacubitril-Valsartan
HFrEF <35: Spirinolactone/Eperenone; resynch, biventricular pacing

78
Q

How are Tachyarrhythmias Tx

How quickly is BP lowered during HTN emergencies using ? med

A

Anticoagulation
Rate/Rhythm: BB, Cardioversion, Ablation, Watchman

IV labetolol
MAP reduced 10-20% in first hr then gradual over 23hrs
Final pressure reduction by 25%

79
Q

ACC/AHA 2017 Stage 1 HTN criteria

JNC8 criteria

What are 4 conditions in older PTs that complicat HTN Dx and management

A

SBP 130-139 or DBP 80-89

Under 60: <140/90
CKD, DM, >60: <150/90

White Coat HTN
Pseudo HTN
OHTON
Post-Prandial HOTN

80
Q

? is the MC indication for major cardiac surgery in older adults after coronary bypass surgery

AR sounds

MS sounds

MR sound

A

AS- harsh systolic murmur; dyspnea, dizzy, syncope

Decrescendo diastolic murmur to L 3/4 ICS

Opening snap, mid-diastolic rumble murmur

Holosystolic murmur at apex, radiates to axilla

81
Q

When do Pts need to prophylactically prevent infective endocarditis

What types of procedures warrant prophylaxis

When is this prophylaxis not recommended

A

Prosthetic heart valve
IE Hx
Congenital heart Dz
Valvulopathy after transplantation

Manipulation of Gingiva, Periapical region or Mucosa

Prior to GI/GU procedures

82
Q

How does Peripheral Artery Dz present

What Dx must this be distinguished from and how

What test result helps confirm this Dx

A

Leg discomfort w/ movement
Rest pain- late
Non-healing ulcers
Gangrene

Spinal stenosis- worse w/ standing/walking; better sitting, knees to chest

ABI <0.9= >50% stenosis
ABI <0.4- ischemia

83
Q

What medication is used for PADz?

Intermittent claudication Sxs are ? related to standing while neurogenic claudicaiton is ? related to standing

? is the third MC cause of CV death in US

A

Cilostazol

IC: never
NC: always

VTE

84
Q

When is a D-dimer useful for VTEs?

How are VTEs Tx

How long are these Tx maintained

A

R/o in low risk PTs

Massive PT- thrombolysis
DOAC/Heparin w/ stockings

3mon w/ discrete cause
6-12mon if no cause

85
Q

PTs w/ VTEs and no identifiable etiology for appropriate age/gender groups, what is the next step?

What is the HAS-BLED acronym for

A

Ca screening

Estimates risk for major bleeds in TPs on anticoagulation to asses risk/benefit in AFib care

HTN
Abnormal kidney/liver function- 1pt each
Stroke
Bleeding
Labile INRs
Elderly >65
Drugs/Alcohol- 1pt each
86
Q

How many points on HAS-BLED correlate to low, med. high risk

What is the only medication approved for dose reduction in older PTs w/ renal impairment needing anticoagulation

When is the use of Rivaroxaban c/i

A

0-1: low
2: mod
3-6: high

Enoxaparin

CrCl <15 mL/min

87
Q

What are PE findings of Chronic Venous Insufficiency

Varicose veins can range from ? to ?

What would be seen on US

A

Hemosiderin staining
Lipodermatosclerosis
Atrophie blanche

Telangiectasis to Ropey varicosities

Venous reflux
Chronic post-thrombotic change

88
Q

Where do Chronic Venous Insufficiency ulcers usually develop?

What are the classifications of Venous Dz

A

Superior to medial malleolus

CO: no visible signs of dz
C1: telangiectasis/reticular veins
C2: varicose veins
C3: edema
C4: trophic skin changes; hyper pigment, eczema atrophie
C5: healed venous ulcer
C6: active venous stasis ulcer
89
Q

Venous Ulcers

A 
Medial malleolus/Calf
Minimal slough, granular/healthy
Little/no pain
Warm limb
Normal pulse
Compress, elevate, moist wound dressing
90
Q

Arterial ulcers

A 
Distal over toe/foot/heel
Dry painful necrotic lesion w/ punched out apearance
Cold limb w/ pallor
No pulses
Tx w/ revascularization
91
Q

How is an acute COPD exacerbation managed

Define COPD

A 
Beta adrenergic agonist- Albuterol, mainstay
Anticholinergic- Ipratropium
PO GCCS- Prednisone
NPPV
ABX

Inflammatory respiratory dz w/ FEV1/FVC <70%

92
Q

Define Emphysema

Define Chronic Bronchitis

Define GOLD Criteria

What is BODE Index for

A

Destruction of alveoli

Cough/sputum x 3mon for 2 consecutive yrs

Tx s by severity stages

Predicts mortality

93
Q

How is COPD Tx

If needed, ? ABX are used?

When do PTs need to be placed on air

A

Chronic: SABA/LABA, GCCS Anticholinergic Rehab
Acute: Prednisone 40-60mg/day x 5d w/ ABX

Mild: Macrolide, Cephalosporin Doxy or TMP
Mod/Sev: Augmentin, Fqn

<88% on room air

94
Q

What are the 4 Gold Categories

A

1: Mild, FEV 80% or highter
2: Mod, FEV 50-80
3: Sev, FEV 30-50
4: Very Sev, FEV <30 or <50 and Chronic Respiratory failure

95
Q

What are the four grades for COPD

How is each Group Tx

A

1: short of breath walking up hill
2: PT has to stop and catch breath, can’t keep up
3: stops after 100ft
4: too breathless to leave house

A: ABA or SAMA
B: LABA or LAMA
C: LAMA
D: LAMA or LAMA and LABA, or LABA and ICS

96
Q

What is the Dx criteria for asthma

What are the two types

CDC recommends PTs >65y/o receive ? two vaccinations?

A

Obstructed airflow w/ FEV/FVC 0.7 or less

Long standing: atopy and allergies
Late onset: obesity, tobacco

Pneumococcal conjugate and Polysacch-23

97
Q

Interstitial Lung Dz

A

FamHx Radiation Interstitial/CT Dz Exposure Smoking

Dry cough Wheeze Chronic exercise intolerance

Restrictive pattern

CXR- honey comb
CT- ground glass

98
Q

How is PulmHTN Dx

What are the 3 Pulm HTN groups

A

Echo w/ Systolic Pulm artery pressure 35-40mm
R heart catheterization of suspected PA-HTN

1: PulmHTN
2: due to L heart Dz
3: due to Lung Dz/Hypoxia
4: due to thromboembolic pulm-HTN
5: multifactorial

99
Q

How does Pancreatic Ca present

What is it’s MC

A 
Jaundice 
Cachexia 
Virchow nodes 
Sister Mary Joseph nodes
Weight loss 
Lethargy

4th leading cause of death from Ca

100
Q

Define Courvoisier Sign

What type of Ca is this associated w/?

What are the MC causes of Upper GI bleeds and the two types

A

Palpable gallbladder due to pancreatic Ca

Adeno

Gastric ulcer- early satiety, immediate pain after meal
Duodenal ulcer- awakes at night, relieved w/ foot, MC than gastric

101
Q

How often do GERD Sxs need to be experienced for Dx

What are complications PTs can develop during Tx on PPIs

A

1/wk

Osteoporosis
C Diff
Drug interactions
Interstitial nephritis

102
Q

What are the 3 categories of HypoNa and their causes

A

Inc ECF:
Urine Na <20: Inc Interstitial Salt- LF Cirrhosis Hepatorenal/Nephrotic syndrome CHF
Urine Na >20: Renal Failure- Hypertonic Saline, Steroids Early diuretics

Normal ECF:
Osmolality urineserum: SIADH; Drugs CNS Pulm Malignancy

Dec ECF:
Urine Na <20: Na loss in excess water- Diarrhea Sweat Vomit Burn Fitula SBO
Urine Na >20: Na and water loss via kidney- KF, Addisons RF Osmotic/Thzd diuresis

103
Q

HypoNa is defined as anything below ? level

What med classes can cause this

HyperNa is define as anything above ?

A

<135

SSRI Diuretic AntiPsych ACE

> 145

104
Q

HypoK is defined as anything below ?

HyperK is define as anything above ?

A

<3.5
Thx/Loops, Extrarenal (GI) Renal

> 5.0
Spironolactone Triamterene Amiloride ACE
Renal/CHF/Cirrhosis, Hypoaldosteronism

105
Q

What medication is added for Anti-HTN in PTs w/ CKD

Routine care for CKD in the primary setting included ?

A

Lisonopril

Monitoring function
Managing CKD complications
Tx CVD RFs
Prevent additional injury
Promote general health
106
Q

What is the goal for geriatric PTs w/ HTN by using ? first line medication classes

What are the goals for their protein-to-creatinine ratio

What is the goal for their LDL?

A

<130/80 w/ ACEI/ARB

<0.2 or ACR <30

<100

107
Q

What test result triad is Dx for primary hypothyroidism

What triad is Dx for Hyperthyroidism

What triad would be seen on results for sub-clinical hyperthyroid and what PE findings may be seen

A

Inc TSH, Low T3,4

Dec TSH, Inc T3,4

Dec TSH, Norm T4
Functional decline
Bone loss
AFib

108
Q

How is subclinical hyperthyroidism Tx

What is the mnemonic saying for HyperCa

What Txs are used

A

Dec Levothyroxine
Iodine 131 ablation

Bones Stones Groans Psych overtones

NS Bisphosphonates Steroids Calcitonin Parathyroidectomy Dialysis if >18mg

109
Q

What needs to be avoided in PTs w/ HyperCa

? is a common endocrine d/o in post-menopause PTs

How are these cases found and Tx

A

Thzds
Bisphosphonates associated w/ jaw necrosis

HyperParathyroidism

HyperCa from adenoma removed w/ surgery

110
Q

? are the MC causes of HyperCa in hospitalized PTs

Adrenal insufficiency is most often from ?

What would be seen on lab results

A

Metastatic ca
Multiple myeloma

Chronic adrenal suppression

HypoNa
HyperK
HypoGlycemia
Abnormal Cosyntropin stim test

111
Q

Even though most adrenal incidentalomas are benign, ? tests are ordered to evaluate them

Equation for Anion Gap

Acronym for DDx of anion gap metabolic acidosis

A

Excess Cortisol Aldosterone Catecholamine production

Na - (Cl + HCO3)

MUDPILES
Methanol Uremia DKA Paraldehyde Iron/Isoniazid Lactic acidosis Ethylene glycol Salicylates

112
Q

Criteria for PT to be Dx w/ Diabetes

What are their A1c goals depending on life expectancy

A

A1c 6.5 or more
Fasting x 8hrs plasma glucose 126 or more
Sxs of hyperglycemia and random glucose 200 or more
2hr plasma glucose 200 or more after 75g glucose

<7 if older and healthy
<8-9 if short life expectancy

113
Q

What are the drug classes used instead of insulin for Diabetes

Lab results show normocytic, normochromic RBCs w/ few reticulocytes, what medication is most appropriate

What conditions is anemia of inflammation/chronic dz associated w/ ?

A

Biguanides- Metformin
SGLT-2 inhibitors- CDEE-flozin
GLP-1 agonists- SLLED-glutide

Darbepoetin

Frality
Vit D deficiency
HIV

114
Q

? is the MC Ca of the urinary system

What are the RFs

A

Bladder Ca

Smoking
Chemicals
Aniline dye
Chlorination
Arsenic
Chronic cystitis
115
Q

What is the next step for central mass found on abnormal CXR?

What is the next step for a peripheral mass found on an abnormal CXR

A

Sputum cytology
Bronchoracic biopsy
Transthoracic biopsy

CT guided biopsy
Thoracoscopy
Thoracotomy

116
Q

Most breast Cas found in geriatrics are ? and Tx w/ ?

What is the MC leukemia of the elderly and how is it Tx

A

ER pos
Endocrine therapy

AML, chemo if fit

117
Q

What is the MC leukemia in adults in western countries

What is found to Dx this condition

What may be found on microscopy

A

CLL/Small lmphocytic lymphoma

Monoclonal proliferation of incompetent mature B cells

Smudge cells- fragile lymphocytes

118
Q

What type of cell finding is indicative of AML

? is the MC cause of non-solid organ Ca related death

How does this MC present

A

Auer rod

Non-hodgkin

Persistent painless peripheral adenopathy

119
Q

What are the Systemic “B” Sxs associated w/ Non-Hogkins

What is the name of the cell finding indicative of Multiple Myeloma

What are the MC presenting complains

A

Fever Weight loss Night sweats

Rouleaux formation

Bone pain in back/ribs

120
Q

What are 5 common infections that are common in older adults

How does acute prostatitis present

PTs may find relief w/ ? ABXs

A

Urinary Respiratory Skin Gastro Osteomyelitis

Refluxed urine into prostate causing tender prostate w/ inc urination

Cipro x 4-6wks
TMP/SMX
FQNs
Ceftriax/Doxy if STI related

121
Q

What are the most likely microbes to cause Acute Prostatitis

? is the MC and most over-Dx bacterial infection in older adults and how does it present

How is this MC Tx

A

E Coli
Proteus
Enterobacter
Pseudomonas

UTIs w/ urge incontinence

ASx- none
TMP/SMx, Macrobid
FQNs for allergy/resistant strains

122
Q

Transudate lab criteria

What are the MC causes

A

Protein 0.5 or less
Pleural/serum LDH 0.6 or less
Plerual fluid LD <2/3 upper limit

HF Cirrhosis Nephrotic PE

123
Q

Exudate lab criteria

What are the MC causes

A

Protein >0.5
Pleural:Serum LDH >0.6
Pleural fluid LDH >2/3 upper

Malignancy
Pneumonia
PE 
Pancreatitis
Esophageal rupture
TB 
Collagen dz
Chylo/hemothorax
124
Q

What tests help w/ Dx influenza/pneumonia infections

What med can be started if Sxs are <72 or severe

What meds are used for pneumonia

A

Ag CXR

Oseltamivir

CAP: Azith/Doxy
W/ comorbidities: Resp FQN or Beta-Lactam Macrolide
HAP: Vanc, Piper-Tazo

125
Q

What is the CURB65 acronym

How is Toxic Megacolon Dx

A

CAP risk stratification:
Confusion Urea +20 Resp +30 BP <90/60 Age >65

Radiographic evidence +3 of:
WBC > 10.5
HR >120
Anemia 
Fever >38*C

And one of:
HOTN E+ disturbance Altered sensorium Dehydrated

126
Q

? is the MC healthcare associated diarrhea

What ABX may be used to Tx

A

C Diff

PO Vanc
Fidaxomicin

127
Q

What ABX are used for Strep/MSSA

What ABX are used for Staph/MRSA

A

1st Gen cephalosporin

Clinda/Doxy

128
Q

How does Erythema Multiforme present

What are the microbe etiologies

What meds can cause this

What systemic dzs can cause it

A

Target lesion rash on palms/soles sparing face and trunk

HSV, Mycoplasma

PCN, Barbituates, Sulfonamide

Lupus Hepatitis Lymphoma

129
Q

What type of skin change appearance is not common an needs to have malignancy r/o

What does Seborrheic Keratosis look like

How are they Tx

A

Benign Nevi

Waxy/stuck on lesion on trunk>extemities/head

Cryotherapy if discomfort to PTs

130
Q

How is stasis dermatitis Tx

What anti-virals are used for Herpes Zoster if Sxs are <72hrs old

What is used for post-rash herpetic neuralgia

A

Class 5 steroid BID for plaques
Diuretics

Acyc/Valacyclovir

Gabapentin

131
Q

How are scabies Tx

What can be used for the pruritis

Everything has to be washed that was touched in past ? days

A

Permethrin cream 5%
PO Ivermectin 0.2mg/kg

Class 1 steroid x 7d

48hrs

132
Q

? is the precursor to SCC

How doe they appear on PE and what is this due to

How is it Tx

A

Actinic Keratosis

Sand paper texture
Sun expsoure

Cryotherapy
Imiquimod/Fluorouracil

133
Q

Ho does BCC and SCC present on PE

What two tests are required for Dx

How are they Tx

A

Firm indurated papule, plaque or nodule

Rolled shave
Punch biopsy

Excision

134
Q

How does malignant melanoma present on PE

What are the first line Tx for Insomnia

A

Brown/Black macule w/ one or more of ABCD >6mm

CBT and Behavior (sleep hygiene)

135
Q

PTs are more likely to have OSA w/ ? Dx

What AHI lab results categorizes apnea as severe/mod/mil

How is this Tx

A

Dementia

Severe: >30/hr
Mod: 16-30/hr
Mild: 5-15/hr

Mod/Sev: CPAP
Mild: devices

136
Q

How is periodic leg movement during sleep assessed

What needs to be r/o

A

Polysomnography

Fe deficiency

137
Q

Bulk forming stool meds

Stool softner

Stool stimulatns

A

Psyllium Methylcellulose

Docusate

Senna Bisacodyl Castor oil

138
Q

Stool lubricants

Stool osmotics

Stool prokinetics

A

Mineral oil

Lactulose Sorbitol Polethylene glycol

Tegaserod Metoclopramide

139
Q

? is the MC non-cutaneous Ca in men

How often is this surveyed after Dx

A

Prostate

PSA q6mon x 5yrs then annually

140
Q

What are the Sxs of BPH

What meds can be used for Tx

A 
HI FUN
Hesitancy
Intermittence/Incontinence
Frequency/Fullness
Urgency
Nocturia

Alpha blockers: DATA-osin
5a-reductase: Finasteride

141
Q

When are prostate screenings recommended

What lab result indicates need for Urology referral

A

PSA 55-69y/o

PSA >4

142
Q

Define Nociceptive Pain

What are the 2 categories

A

Pain from tissue damage

Somatic: injury to tissue, well localized
Visceral: mediated by stretch receptors, deep/dull and poorly localized

143
Q

What are examples of Central Pain

Define Wind-Up Pain

A

Post-stroke
Phantom limb

Pain from C-fibers due to reptitive stimulation from <1stimulus/3seconds, leads to gradual increase of pain

144
Q

XOIs for gout

Uricosuric for gout

A

Allopurinol
Febuxostat

Probenecid

145
Q

How do CPPD crystals appear

What meds are used for Tx

A

Pos birefringent

NSAID/Colchicine

146
Q

What would be seen on PMR lab results

What meds are used for management

A

No RF
Inc ESR/CRP

Steroids

147
Q

What are the 3 categories for back pain

What are red flags for immediate referral to NeuroSurgeon

A

Acute: <4wks
Subacute: 4-12wks
Chronic: >3mon

Cauda Equina
Cord compression
Progressive/Severe Neuro Sxs

148
Q

? is the MC systemic vasculitis in US

This MC is associated w/ ? Dz

This almost never occurs prior to ? age

A

GCA

Polymyalgia Rheumatica

50y/o

149
Q

Reflex Syncope

What are the 4 types

A

Neurally Mediated

Vasovagal
Situational
Carotid sinus
Unknown

150
Q

Orthostatic Syncope

A

Primary autonomic- Parkinson/Lewy body
Drug induced- alcohol dilators diuretics phenothiazides antidepressants
Secondary autonomic- DM amyloidosis Uremia Cord injury
Volume depletion

151
Q

Cardiac syncope

When does syncope need to be considered the cause of a fall

What is the initial assessment done?

A

Brady/Tachy dysrhythmia
Structural dz
Others

Recurrent, LoC, Unexplained

ECG if frequent
Holter/Event monitor for less frequent Sxs

152
Q

What are modifiable risk factors for pressure ulcers

PTs that are at risk to develop these need to be assessed how often?

How often are turning orders written for?

A 
Immobility
Functional impairment
Dry skin
Dec/low BMI
Nutritional status

Daily

2hrs

153
Q

Bedridden PTs need to have head placed nor more than __*

What are the 4 stages of pressure ulcer development

A

30* or lowest level to prevent skin shearing

1: non-blanching
2: partial thickness
3: full thickness into fascia
4: necrosis/destruction to bone

154
Q

When do these injuries NOT need debridment

How are Ulcer Stages 1-2 managed

A

Stable/dry eschar and no signs of infection

Clean w/ NS
Transparent dressing
Remove necrotic tissue

155
Q

How are pressure ulcers stages 3-4 managed

What are 4 possible adverse complications that can develop

A

Irrigate, debrid
Heal w/ secondary intention or surgical closure
Mechanical, enzymatic and autolytic debridment

Cellulitis
Osteomyelitis
Bacteremia
Sepsis

156
Q

When/what ABX is used for pressure ulcers

If ABX is used, it needs to have ? level of coverage

A

No healing after 14days, use Silver Sulfadizaine

MRSA Anaerobes Enterococci Gram Neg

157
Q

Deteriorating ADL/IADLs indicates ?

What are two situations that require accurate functional information

What is the best/most invaluable method to obtain this info

A

Worsening Dz process
Combination of multiple Dxs

Adaptive equipment
Caregiver

OT/PT observation

158
Q

High functioning PTs my not demonstrate functional impairment, what method is more useful in monitoring ADLs?

These changed are AKA

A change in these AKAs can indicate ?

A

Query about target activities:
Bridge Golf Fishing

Advanced ADLs

Dementia
Incontinence
Worsening vision/hearing

159
Q

UTI Tx

When are bisphosphonates c/i

A

Nitro/TMP
No Nitro if GFR <30

GI Ca

160
Q

MOCA Scores

MMCE scores

A

26 or higher, norm

25-30 norm
<24 bad

161
Q

Four ototoxic meds

What med can induce Secondary Acute Angle Closure Glaucoma

A

NSAIDs
Aminoglycosides
Loops
Antimalarial

Topiramate

162
Q

Sequence for PTs w/ full bladder and unable to void

Itching for venous stasis

A

US DRE Foley

Group 5 steroid

163
Q

Venous Ulcer

Arterial Ulcer

A

asdf

164
Q

Trigeminal neuralgia

PHTN definitive Dx

A

New onset face pain, get MRI

R sided cath

165
Q

Don’t give AfAm CCB if ?

BPH HI FUN acronym

A

Constipation
Heart block

Hesitant
Intermittence/Incontinence
Frequency
Urgency
Noctureia
166
Q

USPSTF Grade A

Slide Dec 5

A

HTN

PHTN Classifications

1- idopathic
2- MC, heart dz
3- lung dz/hypoxemia
4- thromboembolism
5- mixed
167
Q

Alzheimer’s w/ hallucinations need ? test

A

Sleep study

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