Geriatrics Flashcards
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?
Function, Social, Psych
Well being/Quality of life
Prognosis
Patient goals
Functional status
Function Independence Dementia
What are the Activities of Daily Living
What are the instrumental activities of daily living?
Continence Feed Toilet
Transfer Bathe Dress
Drive Meds Telephone Shop
Misenplace Clean Laundry Finance
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?
Time to get up from chair
Walk 10ft, return to chair
>30sec= impaired mobility
Falls, Gait
Incidence and Frequency annually
How is gait assessed?
What are the 4 parts of the PTs gait that are assessed?
Can PT rise from chair w/out hands- quad strength
Symmetry Length Height
Width
What are the intrinsic RFs for a fall?
What are the secondary RFs
How can their near/far vision and hearing be tested?
Meds Vision PHOTN
Atrophy Vit D- 800IU/day
Light Footwear Trip hazard Safety
Near- Jaeger
Far- Snellen
Hearing- whisper test
Define the mini cognition test
What is the next step if they fail this test?
How is depression screened for?
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
What are the two questions asked during the PHQ 2 and what are they assessing?
Past 2 wks, felt down, depressed, hopeless- depressive mood
Past 2 wks, felt little interest or pleasure doing things- anhedonia
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
Lens becomes less flexible, less accommodation
Presbyopia
Dec light to retina
? 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
Cataracts
Blurred yellow vision w/ increase sensitivity to glare
Central opacity
Dec red reflex
What is the leading cause of irreversible vision loss in PTs >65y/o
What are the two types and characteristics of each
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
How does Diabetic Retinopathy present
How is it managed
What exam is needed annually
Blurred vision
Field constriction
Scotoma
Observe w/ referral
Dilated funduscopic exam
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
Rapid Painful Monocular
Vision loss
Weber to L
Rinne BC>AC on L
Hearing loss
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
Incident dementia Accelerated cognitive decline Poor neurocognitive function Increase falls Gait disturbance
Sensorineural HL- presbycusis
Perfs Impaction Effusions
What are the Aminoglycoside antibiotics associated w/ hearing loss?
What is the criteria for OHOTN
Gentamicin Amikacin Vancomycin Erythromycin Neomycin Streptomycin
SBP dec 20mm
DBP dec 10mm <3min of Sxs
How is cognitive impairment different from normal aging to concerning?
Define Mild Cognitive Impairement
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
MCI is characterized by what 3 parameters
Subjective complaints validated by second person
Evidence of objective cognitive impairment in one of more domain
Intact functional status
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?
Vascular dementia
Starts at 60
Doublex every 5yrs
What are the 5 types of dementia in order of frequency and RFs for each
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
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
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
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
> 80y/o
q6-12mon
Cognitive decline, suggests Dx of MCI, dementia
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?
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
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
Depression
Can be cause of cognitive defecits
Must be ID’d/r/o prior to Dx of dementia
Memory complaints OOP to deficits
Define Delirium
What is the classic triad for Alzeimers
Sensory deficit Other psych d/0 Delerium Depression Alcohol abuse Meds- BEERS LIST
Memory impairment
Visuospatial problems
Language impairment
Alzheimer
Early: retain social function, fail complex tasks
Disorientation:
Time Place Person
Languae:
Anomic Fluent Mutism
Lost in familiar places
Behavior changes common
Lewy Body Dementia
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
Vascular Dementia
Dx base on radiographic evidence of cerebrovascular dz
Sudden onset after stroke/step wise, not continuous
Patchy deficit, not as severe as Alzheimer
Fronto Temporal Dementia
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
What meds are used in Dementia Tx for Cognitive Impairement
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
How is Vascular dementia Tx
What non-pharmaceutical Tx can be done for behavior problems
Tx RFs for stroke:
Tobacco HLD AFib DM
Permissive HTN- SBP 150+
Consider ChEI (GRD), Memantine
Bright light Music Walk Pets
What meds can be used for Dementia induced behavior problems?
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
What Tx methods are not recommended for dementia due to lack of efficacy/potential for harm?
What are the criteria for major depression
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
What screening tool is used for detecting depression in in older adults?
What are the DDxs?
PHQ-2
Delirium
Cognitive impairment
Chronic medical condition (weak/fatigue)
What meds are used for depression in adults and their s/e
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
What are the risks of SSRIs as a class
What are the risks of TCAs
Seratonin Syndrome HTN HypoNa Inc bleeding risk w/ anti-coagulants Fall risk
OD
OHOTN
Arrhythmia
Cognitive impairment
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
Mania/Psychosis
Failure x 2 meds
Electroconvuslive therapy
RF for SI
TSH Warfarin Phenytoin
Anticoagulant/platelets
Diabetes
What is the two types of Pneumoccoccal vaccine given at 65y/o
When are herpes zoster vaccines given?
What age are cervical screenings stopped
PPSV23 and PCV 13
50y/o
65y/o
When are lung CTs needed for smoking PTs
When is osteoporosis screened for ?
How often is hyperlipidemia screened for
55-80y/o w/ 30ppy or quit <15yrs
F >65y/o, initial
M >70y/o, consider
Initial, q5yrs
Urgency Incontinence Sxs
Causes
Tx
Detrusor over activity- Involuntary loss followed w/ urgency
Stroke
Alzeihmers/Parkinson
BPH w/ overflow
Anticholinergic
Stress urinary incontinence Sxs
Causes
Tx
Loss of urine w/ strain/exertion from sphincter failure
Pelvic floor weakness (surgery/birth)
Prostate surgery Hx
Topical estrogen
Mixed urinary incontinence Sxs
Causes
Involuntary loss of urine w/ urge and w/ exertion/stress
Combo of urge and stress
Overflow incontinence Sxs
Causes
Tx
Weak stream, incomplete emptying
BPH
Impaction/fibroids
Diabetic neuropathy
Pelvic organ prolapse
Alpha adrenergic blockers
PT presents w/ stress urinary incontinence, what test is used to confirm Dx?
What two tests can be ordered for urinary incontinence
Bladder stress test
UUI: bladder competence/detrusor over activity
SUI: urethra function, post-void residual
How do anticholinergics contribute to urinary incontinence?
How do diuretics contribute to urinary incontinence?
How do opioids contribute to urinary incontinence?
Affect bladder wall/sphincter
Inc volume/diuresis
Receptor induced dysfunction
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?
Urethral sphincter constriction
Urethral sphincter relaxation
Dec smooth muscle contractility
How is stress incontinence Tx
How is Urge incontinence Tx
How is overflow Tx
Kegels/Pessaries
Estrogen
Surgery
Estrogen
Antimuscarinic- Oxybutynin
B-agonists- Mirabegron
Alpha blocker- Doxazosin
5a inhibitors- Finasteride
Cath/Surgery
Define Scoliosis
Define Kyphosis
Define Lordosis
Spine is C or S shaped
Thoracic spine curves out
Lumbar spine curves inward
How does OA present
What will be seen on PE
What would be seen on x-rays
Mechanical pain worse w/ activity, better w/ rest
Joint line tenderness w/ bone enlargements
Narrowing, osteophytes, sclerosis and cysts
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
Acetaminophen- initial choice
NSAIDs- acetaminophen failure
Tramadol
Hip Vertebrae Wrist
FRAX
What are the three classifications of osteoporosis
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
What DEXA measurements correlate to normal and osteoporosis
When are DEXA scans recommended
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
What meds are given for Osteopenia
What DEXA score is osteopenia but is changed to porosis based on criteria
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
What lab tests are ordered for Secondary causes of osteoporosis
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
What meds are first line Tx for Osteoporosis
What selective estrogen receptor modulator may be sued
Bisphosphonates-
AIR-onate
Zoledronic acid
Raloxifene
Delirium
Abrupt onset that fluctuates over hrs-wks
Impaired attention, alertness, orientation
Disrupted sleep-wake cycle
Agitated/withdrawn
Dementia
Insidious onset w/ slow decline over mon-yrs
Attention intact early, impaired later in dz
Normal sleep, alertness
What is pathognemonic for delirium
What other key features may be seen
Acute change in baseline mental status over hrs/days
Fluctuating Rambling Alerted LoC Inattention Disorganized thinking
What is the leading precipitating factor to delirium
What are examples of this leading cause
Medications
Sedative hypnotics Opiates Anticholinergics Polypharm Benzos ETOH TCAs CCS H2 receptor antagonists
? may be the first sign of serious underlying dz
What must be carefully r/o
Delirium
Occult infection
Define the Confusion Assessment Method
What are two features not seen in mild/mod dementia
Worsening confusion above baseline cognitive impairment suggests ? Dx
Acute onset, fluctuating and,
Inattention and
Disorganized thought or Altered LoC
Inattention
Altered LoC
Delirium
What are the steps of delirium Tx
What meds are last line choices for Tx
What needs to be avoided
ID/Tx underlying cause
Eradicate contributing factors
Manage Sxs
Risperidone Olanzapine Benzos
Haldol Quetiapine
Restraints
What are the 4 characteristics of Parkinsons
What causes these Sxs
What is the name of the gait they adopt
Bradykinesia
Muscle rigidity- cog wheel
Posture instability- late
Resting tremor- pill rolling
Loss of substantia nigra and depletion of dopamine
Festinating
? 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
Parkinsons
> 75
Bradykinesia plus 1 Sx
? is the MC cause of Parkinson’s
What presentations are red flags for secondary causes
What is the strongest alerting factor
Idiopathic
Symmetric
Lack of tremor
Atypical features
Lack of response to high dose of dopamine/Levodopa
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
Antiemetic/psychotic
Atypical Parkinsons- associated w/ disabling features (autonomic failure, early fall/dementia)
1: SSRI, 2: SNRI
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
Anti-HTN
Pramipexole- dopamine agonist
S/e: drowsy hallucinations risk-taking behavior
? 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
> 70:Levodopa
<70: Pramipexole, Ropinirole
Pramipexole
Amantadine
Ropinirole
Anticholinergics
DOPA-decarboxylase
What features of Parkinson respond less to Levodopa than other Sxs
What PT education has to occur w/ these meds
MOA of Carbidopa
Axial- speech/gait
30min before meal
Decarboxylase inhibitor, prevents peripheral Levodopa to dopamine
What are the 3 types of Tremors, PE findings and causes
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
What medication can be added for PTs presenting w/ essential tremors
How do these present
What are the first and second line Txs
Propranolol
S/e- HOTN Brady Broncho constriction
Forearm, head, voice, trunk bilateral, postural-kinetic
1st: Primidone Occupational therapy Propranolol 2nd: Gabapentin/Topiramate Unilateral thalamotomy
How do strokes present
What are the two categories
What are the 3 parts of the Cincinnati stroke scale
Neuro deficit or HA of abrupt onset
Ischemic
Hemorrhagic: Intracerebral, SubArachnoid
Facial droop
Arm drift
Speech
What are the two phases of Cerebrovascular Dz diagnostics
What are the Ischemic Stroke Sub-types
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
What is the underlying etiology for intracerebral hemorrhages
Inclusion criteria for administering tPA for ischemic strokes
HTN
Cerebral amyloid angiopathy
Anti-coagulation related hemorrhage
Sx onset <4.5hrs
18y/o or older
Dx of ischemic stroke causing neuro deficits
What are the considerations for pushing tPA in acute ischemic strokes
What are the antiplatelet agents first chosen for non-cardioembolic CVDz
3hrs of Sx onset
Extended to 4.5hrs if <80y/o
BP <185/110
ASA
Clopidogrel
Dipyridamole and ASA
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
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
What are the 3 main mechanisms of TIAs
How does Takotsubo Cardiomyopathy present
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
What would be seen on imaging of a Takotsubo PT
What meds are used for chronic/long term therapy in coronary artery Dz PTs
Octopus pot- apical ventricle ballooning
Statin
Anti-platelet
BBs
ACE/ARB if HFrEF
What medication is used to Tx dilated cardiomyopathy
What meds are used for different types of HF
BB- Bisoprodol
HFrEF >50: control HTN, Na intake, daily weight, Loops
HFrEF <40: BB and Sacubitril-Valsartan
HFrEF <35: Spirinolactone/Eperenone; resynch, biventricular pacing
How are Tachyarrhythmias Tx
How quickly is BP lowered during HTN emergencies using ? med
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%
ACC/AHA 2017 Stage 1 HTN criteria
JNC8 criteria
What are 4 conditions in older PTs that complicat HTN Dx and management
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
? is the MC indication for major cardiac surgery in older adults after coronary bypass surgery
AR sounds
MS sounds
MR sound
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
When do Pts need to prophylactically prevent infective endocarditis
What types of procedures warrant prophylaxis
When is this prophylaxis not recommended
Prosthetic heart valve
IE Hx
Congenital heart Dz
Valvulopathy after transplantation
Manipulation of Gingiva, Periapical region or Mucosa
Prior to GI/GU procedures
How does Peripheral Artery Dz present
What Dx must this be distinguished from and how
What test result helps confirm this Dx
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
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
Cilostazol
IC: never
NC: always
VTE
When is a D-dimer useful for VTEs?
How are VTEs Tx
How long are these Tx maintained
R/o in low risk PTs
Massive PT- thrombolysis
DOAC/Heparin w/ stockings
3mon w/ discrete cause
6-12mon if no cause
PTs w/ VTEs and no identifiable etiology for appropriate age/gender groups, what is the next step?
What is the HAS-BLED acronym for
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
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
0-1: low
2: mod
3-6: high
Enoxaparin
CrCl <15 mL/min
What are PE findings of Chronic Venous Insufficiency
Varicose veins can range from ? to ?
What would be seen on US
Hemosiderin staining
Lipodermatosclerosis
Atrophie blanche
Telangiectasis to Ropey varicosities
Venous reflux
Chronic post-thrombotic change
Where do Chronic Venous Insufficiency ulcers usually develop?
What are the classifications of Venous Dz
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
Venous Ulcers
Medial malleolus/Calf Minimal slough, granular/healthy Little/no pain Warm limb Normal pulse Compress, elevate, moist wound dressing
Arterial ulcers
Distal over toe/foot/heel Dry painful necrotic lesion w/ punched out apearance Cold limb w/ pallor No pulses Tx w/ revascularization
How is an acute COPD exacerbation managed
Define COPD
Beta adrenergic agonist- Albuterol, mainstay Anticholinergic- Ipratropium PO GCCS- Prednisone NPPV ABX
Inflammatory respiratory dz w/ FEV1/FVC <70%
Define Emphysema
Define Chronic Bronchitis
Define GOLD Criteria
What is BODE Index for
Destruction of alveoli
Cough/sputum x 3mon for 2 consecutive yrs
Tx s by severity stages
Predicts mortality
How is COPD Tx
If needed, ? ABX are used?
When do PTs need to be placed on air
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
What are the 4 Gold Categories
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
What are the four grades for COPD
How is each Group Tx
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
What is the Dx criteria for asthma
What are the two types
CDC recommends PTs >65y/o receive ? two vaccinations?
Obstructed airflow w/ FEV/FVC 0.7 or less
Long standing: atopy and allergies
Late onset: obesity, tobacco
Pneumococcal conjugate and Polysacch-23
Interstitial Lung Dz
FamHx Radiation Interstitial/CT Dz Exposure Smoking
Dry cough Wheeze Chronic exercise intolerance
Restrictive pattern
CXR- honey comb
CT- ground glass
How is PulmHTN Dx
What are the 3 Pulm HTN groups
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
How does Pancreatic Ca present
What is it’s MC
Jaundice Cachexia Virchow nodes Sister Mary Joseph nodes Weight loss Lethargy
4th leading cause of death from Ca
Define Courvoisier Sign
What type of Ca is this associated w/?
What are the MC causes of Upper GI bleeds and the two types
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
How often do GERD Sxs need to be experienced for Dx
What are complications PTs can develop during Tx on PPIs
1/wk
Osteoporosis
C Diff
Drug interactions
Interstitial nephritis
What are the 3 categories of HypoNa and their causes
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
HypoNa is defined as anything below ? level
What med classes can cause this
HyperNa is define as anything above ?
<135
SSRI Diuretic AntiPsych ACE
> 145
HypoK is defined as anything below ?
HyperK is define as anything above ?
<3.5
Thx/Loops, Extrarenal (GI) Renal
> 5.0
Spironolactone Triamterene Amiloride ACE
Renal/CHF/Cirrhosis, Hypoaldosteronism
What medication is added for Anti-HTN in PTs w/ CKD
Routine care for CKD in the primary setting included ?
Lisonopril
Monitoring function Managing CKD complications Tx CVD RFs Prevent additional injury Promote general health
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?
<130/80 w/ ACEI/ARB
<0.2 or ACR <30
<100
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
Inc TSH, Low T3,4
Dec TSH, Inc T3,4
Dec TSH, Norm T4
Functional decline
Bone loss
AFib
How is subclinical hyperthyroidism Tx
What is the mnemonic saying for HyperCa
What Txs are used
Dec Levothyroxine
Iodine 131 ablation
Bones Stones Groans Psych overtones
NS Bisphosphonates Steroids Calcitonin Parathyroidectomy Dialysis if >18mg
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
Thzds
Bisphosphonates associated w/ jaw necrosis
HyperParathyroidism
HyperCa from adenoma removed w/ surgery
? are the MC causes of HyperCa in hospitalized PTs
Adrenal insufficiency is most often from ?
What would be seen on lab results
Metastatic ca
Multiple myeloma
Chronic adrenal suppression
HypoNa
HyperK
HypoGlycemia
Abnormal Cosyntropin stim test
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
Excess Cortisol Aldosterone Catecholamine production
Na - (Cl + HCO3)
MUDPILES
Methanol Uremia DKA Paraldehyde Iron/Isoniazid Lactic acidosis Ethylene glycol Salicylates
Criteria for PT to be Dx w/ Diabetes
What are their A1c goals depending on life expectancy
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
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/ ?
Biguanides- Metformin
SGLT-2 inhibitors- CDEE-flozin
GLP-1 agonists- SLLED-glutide
Darbepoetin
Frality
Vit D deficiency
HIV
? is the MC Ca of the urinary system
What are the RFs
Bladder Ca
Smoking Chemicals Aniline dye Chlorination Arsenic Chronic cystitis
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
Sputum cytology
Bronchoracic biopsy
Transthoracic biopsy
CT guided biopsy
Thoracoscopy
Thoracotomy
Most breast Cas found in geriatrics are ? and Tx w/ ?
What is the MC leukemia of the elderly and how is it Tx
ER pos
Endocrine therapy
AML, chemo if fit
What is the MC leukemia in adults in western countries
What is found to Dx this condition
What may be found on microscopy
CLL/Small lmphocytic lymphoma
Monoclonal proliferation of incompetent mature B cells
Smudge cells- fragile lymphocytes
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
Auer rod
Non-hodgkin
Persistent painless peripheral adenopathy
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
Fever Weight loss Night sweats
Rouleaux formation
Bone pain in back/ribs
What are 5 common infections that are common in older adults
How does acute prostatitis present
PTs may find relief w/ ? ABXs
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
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
E Coli
Proteus
Enterobacter
Pseudomonas
UTIs w/ urge incontinence
ASx- none
TMP/SMx, Macrobid
FQNs for allergy/resistant strains
Transudate lab criteria
What are the MC causes
Protein 0.5 or less
Pleural/serum LDH 0.6 or less
Plerual fluid LD <2/3 upper limit
HF Cirrhosis Nephrotic PE
Exudate lab criteria
What are the MC causes
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
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
Ag CXR
Oseltamivir
CAP: Azith/Doxy
W/ comorbidities: Resp FQN or Beta-Lactam Macrolide
HAP: Vanc, Piper-Tazo
What is the CURB65 acronym
How is Toxic Megacolon Dx
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
? is the MC healthcare associated diarrhea
What ABX may be used to Tx
C Diff
PO Vanc
Fidaxomicin
What ABX are used for Strep/MSSA
What ABX are used for Staph/MRSA
1st Gen cephalosporin
Clinda/Doxy
How does Erythema Multiforme present
What are the microbe etiologies
What meds can cause this
What systemic dzs can cause it
Target lesion rash on palms/soles sparing face and trunk
HSV, Mycoplasma
PCN, Barbituates, Sulfonamide
Lupus Hepatitis Lymphoma
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
Benign Nevi
Waxy/stuck on lesion on trunk>extemities/head
Cryotherapy if discomfort to PTs
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
Class 5 steroid BID for plaques
Diuretics
Acyc/Valacyclovir
Gabapentin
How are scabies Tx
What can be used for the pruritis
Everything has to be washed that was touched in past ? days
Permethrin cream 5%
PO Ivermectin 0.2mg/kg
Class 1 steroid x 7d
48hrs
? is the precursor to SCC
How doe they appear on PE and what is this due to
How is it Tx
Actinic Keratosis
Sand paper texture
Sun expsoure
Cryotherapy
Imiquimod/Fluorouracil
Ho does BCC and SCC present on PE
What two tests are required for Dx
How are they Tx
Firm indurated papule, plaque or nodule
Rolled shave
Punch biopsy
Excision
How does malignant melanoma present on PE
What are the first line Tx for Insomnia
Brown/Black macule w/ one or more of ABCD >6mm
CBT and Behavior (sleep hygiene)
PTs are more likely to have OSA w/ ? Dx
What AHI lab results categorizes apnea as severe/mod/mil
How is this Tx
Dementia
Severe: >30/hr
Mod: 16-30/hr
Mild: 5-15/hr
Mod/Sev: CPAP
Mild: devices
How is periodic leg movement during sleep assessed
What needs to be r/o
Polysomnography
Fe deficiency
Bulk forming stool meds
Stool softner
Stool stimulatns
Psyllium Methylcellulose
Docusate
Senna Bisacodyl Castor oil
Stool lubricants
Stool osmotics
Stool prokinetics
Mineral oil
Lactulose Sorbitol Polethylene glycol
Tegaserod Metoclopramide
? is the MC non-cutaneous Ca in men
How often is this surveyed after Dx
Prostate
PSA q6mon x 5yrs then annually
What are the Sxs of BPH
What meds can be used for Tx
HI FUN Hesitancy Intermittence/Incontinence Frequency/Fullness Urgency Nocturia
Alpha blockers: DATA-osin
5a-reductase: Finasteride
When are prostate screenings recommended
What lab result indicates need for Urology referral
PSA 55-69y/o
PSA >4
Define Nociceptive Pain
What are the 2 categories
Pain from tissue damage
Somatic: injury to tissue, well localized
Visceral: mediated by stretch receptors, deep/dull and poorly localized
What are examples of Central Pain
Define Wind-Up Pain
Post-stroke
Phantom limb
Pain from C-fibers due to reptitive stimulation from <1stimulus/3seconds, leads to gradual increase of pain
XOIs for gout
Uricosuric for gout
Allopurinol
Febuxostat
Probenecid
How do CPPD crystals appear
What meds are used for Tx
Pos birefringent
NSAID/Colchicine
What would be seen on PMR lab results
What meds are used for management
No RF
Inc ESR/CRP
Steroids
What are the 3 categories for back pain
What are red flags for immediate referral to NeuroSurgeon
Acute: <4wks
Subacute: 4-12wks
Chronic: >3mon
Cauda Equina
Cord compression
Progressive/Severe Neuro Sxs
? is the MC systemic vasculitis in US
This MC is associated w/ ? Dz
This almost never occurs prior to ? age
GCA
Polymyalgia Rheumatica
50y/o
Reflex Syncope
What are the 4 types
Neurally Mediated
Vasovagal
Situational
Carotid sinus
Unknown
Orthostatic Syncope
Primary autonomic- Parkinson/Lewy body
Drug induced- alcohol dilators diuretics phenothiazides antidepressants
Secondary autonomic- DM amyloidosis Uremia Cord injury
Volume depletion
Cardiac syncope
When does syncope need to be considered the cause of a fall
What is the initial assessment done?
Brady/Tachy dysrhythmia
Structural dz
Others
Recurrent, LoC, Unexplained
ECG if frequent
Holter/Event monitor for less frequent Sxs
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?
Immobility Functional impairment Dry skin Dec/low BMI Nutritional status
Daily
2hrs
Bedridden PTs need to have head placed nor more than __*
What are the 4 stages of pressure ulcer development
30* or lowest level to prevent skin shearing
1: non-blanching
2: partial thickness
3: full thickness into fascia
4: necrosis/destruction to bone
When do these injuries NOT need debridment
How are Ulcer Stages 1-2 managed
Stable/dry eschar and no signs of infection
Clean w/ NS
Transparent dressing
Remove necrotic tissue
How are pressure ulcers stages 3-4 managed
What are 4 possible adverse complications that can develop
Irrigate, debrid
Heal w/ secondary intention or surgical closure
Mechanical, enzymatic and autolytic debridment
Cellulitis
Osteomyelitis
Bacteremia
Sepsis
When/what ABX is used for pressure ulcers
If ABX is used, it needs to have ? level of coverage
No healing after 14days, use Silver Sulfadizaine
MRSA Anaerobes Enterococci Gram Neg
Deteriorating ADL/IADLs indicates ?
What are two situations that require accurate functional information
What is the best/most invaluable method to obtain this info
Worsening Dz process
Combination of multiple Dxs
Adaptive equipment
Caregiver
OT/PT observation
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 ?
Query about target activities:
Bridge Golf Fishing
Advanced ADLs
Dementia
Incontinence
Worsening vision/hearing
UTI Tx
When are bisphosphonates c/i
Nitro/TMP
No Nitro if GFR <30
GI Ca
MOCA Scores
MMCE scores
26 or higher, norm
25-30 norm
<24 bad
Four ototoxic meds
What med can induce Secondary Acute Angle Closure Glaucoma
NSAIDs
Aminoglycosides
Loops
Antimalarial
Topiramate
Sequence for PTs w/ full bladder and unable to void
Itching for venous stasis
US DRE Foley
Group 5 steroid
Venous Ulcer
Arterial Ulcer
asdf
Trigeminal neuralgia
PHTN definitive Dx
New onset face pain, get MRI
R sided cath
Don’t give AfAm CCB if ?
BPH HI FUN acronym
Constipation
Heart block
Hesitant Intermittence/Incontinence Frequency Urgency Noctureia
USPSTF Grade A
Slide Dec 5
HTN
PHTN Classifications
1- idopathic 2- MC, heart dz 3- lung dz/hypoxemia 4- thromboembolism 5- mixed
Alzheimer’s w/ hallucinations need ? test
Sleep study
