Geriatrics (+ stroke) Flashcards

Question

What are complications of stroke you will have to manage?

Answer 1

- DVT risk = stockings, flowtrons - pressure sores = from immobility - nil by mouth due to poor swallowing

Answer 2

- stop smoking - exercise - good diet - alcohol cessation - driving advice = 1 month normally, 6-12 months for HGVs

Answer 3

Dual anti platelet 75mg of aspirin + clopidogrel

Answer 4

- antiplatelets = aspirin +/or clopidogrel then clopidogrel for lifelong - anticoagulation = prevent blood clots in a low pressure system CHADVASc for stroke ORBIT score for risk of bleeding - hypertension Acute : risk of hypo perfusion Chronic: long term blood pressure targets of <130/80 - diabetes - cholesterol

Answer 5

sudden severe headache

Answer 6

1. ABCDE 2. blood pressure 3. bleeding tendency

Answer 7

- seizures - SOL - migraine - metabolic (hypoglycaemia or hyponatraemia) - functional neurological disorder (hoover's sign) - vestibular neuritis/ other causes of vertigo - spinal cord/peripheral nerve/ cranial nerve lesions

Answer 8

Warfarin reversal = beriplex and vitamin K Heparin = portamine Apixaban/riavroxaabn = beriplex

Answer 9

Bell's LMN lesion can't crease forehead onset hours -days treat with steroids stroke - sudden onset - forehead spring - UMN lesion - treat with thrombolysis

Answer 10

Sudden onset focal neurological deficit. Older definition: symptoms of a stroke that resolve within 24 hours. New definition: transient neurological dysfunction secondary to ischaemia without infarction. Either time based or tissue based DOES NOT CAUSE ACUTE INFARCTION

Answer 11

Depends on the site of the TIA: ACA - weak/numb contralateral leg MCA - weak/numb contralateral side of body, face drooping w/forehead spared, dysphasia (temporal) PCA -Homonymous hemianopia: visual field loss on the same side of both eyes Hemisensory loss Amaurosis fugax

Answer 12

Diplopia – double vision Vertigo Vomiting Choking and dysarthria Ataxia Hemisensory loss

Answer 13

ABCD2 score – risk score of strokes (max score is 7) A – Age – > 60 (1 point) B – Blood pressure (at presentation), 140/90 or more (1 point) C – Clinical features: Unilateral weakness (2 points), Speech disturbance without weakness (1 point) D – Duration, 60 minutes or longer (2 points), 10-59 minutes (1 point) D – Presence of diabetes (1 point) High risk: ABCD2 score of 4 or more, AF is present, More than TIA in one week or a TIA whilst on anti-coagulation Low risk: None of the above Present more than a week after their last symptoms have resolved

Answer 14

1. The Face Arm Speech Time Test (FAST test): check for/ ask about facial weakness, arm weakness, speech difficulty - ECG: rule out AF as an underlying cause - Auscultation: listen for carotid bruit - Bloods: PT time/INR - in case thrombolytic therapy is needed To exclude hypoglycaemia/hyponatraemia FBC – looking for polycythaemia - CT scan - Request an urgent CT scan of the head - Carotid doppler – look for stenosis - CT angiography – look for stenosis

Answer 15

1. Immediate management Aspirin 300mg Refer to specialist – to be seen within 24h of symptom onset 2. Antiplatelet therapy Standard treatment is Aspirin 75mg daily With modified-release Dipyridamole OR Clopidogrel daily

Answer 16

Carotid endarterectomy: surgical procedure to remove the blockage, Done within 2 weeks stenosis of > 70% on Doppler is an indication for urgent endarterectomy

Answer 17

- Statin = atorvastatin 20-80mg OD - Anticoagulant for AF e.g. low molecular weight heparin e.g. dalteparin OR direct thrombin inhibitor OR factor Xa inhibitor rivaroxaban - Give aspirin 300mg OD for 2wks then switch to 75mg clopidogrel OD

Answer 18

Increased risk of stroke Increased risk of underlying CVD You cant distinguish until after recovery TIA Sx resolve usually within/<24 hours Stroke Sx last more than 24 hours

Answer 19

Intracerebral: bleeding within the brain parenchyma Subarachnoid: bleeding into the subarachnoid space, between the pia mater and arachnoid mater of the meninges Intraventricular: bleeding within the ventricles which stop CSF; prematurity is a very strong risk factor in infants Intraparenchymal haemorrhage: An intracerebral haemorrhage that involves just the brain tissue

Answer 20

- Hypertension - Arteriovenous malformations: blood vessels that directly connect an artery to a vein. Over time these abnormal vessels dilate and can rupture - Vasculitis - Vascular tumours - aka Haemangioma - Cerebral amyloid angiopathy: a degenerative disease where abnormal protein deposits in the walls of arterioles making them less compliant - Head trauma

Answer 21

Ischaemia causes brain tissue death. If there is reperfusion, there’s an increased chance that the damaged blood vessel might rupture. Bleeding into dead tissue is called haemorrhagic conversion.

Answer 22

pool of blood which increases pressure in the skull and puts direct pressure on nearby tissue cells and blood vessels downstream tissue from bleed are also deprived of oxygen-rich blood. Healthy tissue can die from both the direct pressure and the lack of oxygen Increased ICP can also lead to CSF obstruction, - Hydrocephalus Midline shift Tentorial herniation

Answer 23

Similar to an ischaemic stroke - brain region specific - Headache - Weakness - Seizures - Vomiting - Reduced consciousness 1. Anterior or middle cerebral artery stroke: numbness and sudden muscle weakness. 2. Broca’s area or Wernicke’s area stroke: slurred speech or difficulty understanding speech, respectively. 3. Posterior cerebral artery stroke: vision disturbances.

Answer 24

1. Request an immediate non-contrast CT scan of the head - will see hyperattenuation (brightness), suggesting acute blood, often with surrounding hypoattenuation (darkness) due to oedema 2. Angiography: visualise the exact location of haemorrhage 3. Check FBC and clotting

Answer 25

1. Consider intubation, ventilation and ICU care if they have reduced consciousness 2. Correct any clotting abnormality - STOP ANTICOAGULANTS IF PT IS ON THEM 3. Correct severe hypertension but avoid hypotension Craniotomy, or stereotactic aspiration 4. Drugs to relieve ICP - IV MANITOL

Answer 26

elevates blood plasma osmolality, resulting in enhanced flow of water from tissues, including the brain and cerebrospinal fluid, into interstitial fluid and plasma Mannitol hinders tubular reabsorption of water and enhances excretion of sodium and chloride by elevating the osmolarity of the glomerular filtrate.

Answer 27

1. Trauma 2. Atraumatic cases are referred to as spontaneous SAH - often due to a saccular cerebral (Berry) Aneurysm - 70-80% of SAH cases 3. Arteriovenous malformation(AVM) - abnormal connections between artery and vein can dilate and cause rupture - 15% of SAH cases Can be Idiopathic

Answer 28

Rupture of blood vessel - leads to a rise in ICP, Pressure on healthy tissues can make them die, as well as brain tissue not getting blood it needs due to bleed - Ischaemia Vessels being bathed in a pool of blood can cause vasospasm - will further reduce the supply of blood flow to the brain Also can irritate the meninges, which can lead to scarring which can obstruct CSF outflow ==> Hydrocephalus

Answer 29

- Neck stiffness - Budzinski’s Sign - Flexion of neck = Flexion of Knees - Kernig sign - Knee cannot be fully extended with hip flexed at 90 degrees - Focal neurological deficit - eg if affecting Posterior cerebral artery - Oculomotor palsy - Increased BP - ‘Thunderclap’ headache - Meningism: photophobia and neck stiffness - due to Meningies irritation - Vision changes - Nausea and vomiting - Speech changes - Seizures - Papilledema

Answer 30

Migraine Meningitis Corticol vein thrombosis Carotid/vertebral artery dissection

Answer 31

1. Urgent Non Contrast CT head ASAP Detects >95% of SAH in first 24 hours - Subarachnoid and/or intraventricular blood, hyperdense areas in the subarachnoid space “Star” shaped sign - or hyerdense blood in the gyri - as blood is not in the brain tissue, but on top of the pia mata 2. ECG - Arrhythmias and ischaemic changes, Prolonged QTc, ST segment/T-wave abnormalities. 3. Lumbar puncture – if CT normal but SAH still suspected Findings - RBCs or xanthochromia (yellow pigmentation due to degradation of haemoglobin to bilirubin) 4. Electrolytes - Moderate hyponatraemia 5. ABG – to rule out hypoxia

Answer 32

Immediately refer to neurosurgeon 1. Nimodipine - Ca2+ antagonist, (CCB) Reduces vasospasm and therefore cerebral ischaemia 2. Re-examine CNS often 3. IV fluids -Maintain cerebral perfusion Ventricular drainage for hydrocephalus 4. IV mannitol + head elevation (30°) + intubation with hyperventilation = If features of raised intracranial pressure

Answer 33

1. endovascular coilingo f the aneurysm - reduces blood circulation to the aneurysm inserting one or more microsurgical detachable platinum wires, into the aneurysm until there is no more blood flow occurring. Usually enter through leg. 2. surgical clipping via craniotomy - opening in the skull is created to reach the aneurysm. Then small metal clip on the neck (opening) of the aneurysm to obstruct the flow of blood.

Answer 34

A bleed ABOVE the dura mater, between the outer endosteal of the dura and the skull.

Answer 35

Pterion = where the frontal, parietal, temporal and sphenoid bones join together - relatively thin - located right above the middle meningeal artery

Answer 36

- Head injury - Reduced GCS: loss of consciousness after the trauma due to concussion - There might be a LUCID INTERVAL after initial trauma if there is a slower bleed. This is followed by rapid decline. ==> Therefore, if suspect a fracture/bleed in head injury, they need a scan! Headaches Vomiting Confusion Seizures Pupil dilation if bleeding continues May be focal neurological symptoms e.g. muscle weakness, hemiparesis, abnormal plantar reflex (upgoing plantar) or sensory problems

Answer 37

CT scan – shows biconvex hyperdense haematoma that is adjacent to the skull - Blood forms rounded/biconvex shape as the tough dural attachments to the skull keep it more localised - Don’t cross suture lines Skull X-ray – may be normal or show fracture lines crossing the course of the middle meningeal artery - Skull fracture increases the extradural haemorrhage risk so do an urgent CT on anyone with suspected skull fracture

Answer 38

Edinger-Westphal nucleus disrupts the normal regulation of pupil size by interfering with the parasympathetic innervation, as well as the occulomotoro nerve

Answer 39

Rupture of bridging veins, usually caused by: - Brain atrophy: in the elderly the brain shrinks in size which means that the bridging veins are stretched across a wider space where they are largely unsupported - Alcohol abuse: caused the wall of the veins to thin out, and make them more likely to break. - Trauma/ injury e.g. - Falls - Shaken baby syndrome - Acceleration-deceleration injury: speeding on the road and then suddenly slamming the brakes

Answer 40

- Reduced GCS: loss of consciousness right after the injury or in the ensuing days to weeks as the haematoma increases in size. - Headaches - Vomiting - Seizures - Sometimes there can be focal neurological symptoms e.g. muscle weakness, unequal pupils, hemiparesis or sensory problems - Confusion - May fluctuate Insidious physical & intellectual slowing - Personality change - Unsteadiness They often cannot remember the traumatic injury as it was long ago

Answer 41

Immediate NON CONTRAST CT head to establish the diagnosis. - Shows clot and midline shift. Bleeding is between the dura and arachnoid so subdural haematomas follow the contour of the brain and form a crescent-shape and cross suture lines. This is different to an epidural haemorrhage! Check FBC and clotting

Answer 42

1. Acute subdural haematoma: hyperdense mass = looks “more white” than the surrounding healthy brain tissue 2. Chronic subdural haematoma: hypodense masses = “less white” than the surrounding brain tissue. 3. Acute on chronic bleeding: combination of hyperdense and hypodense, seen in individuals who have a rebleed in the bridging veins after a chronic haematoma has already formed.

Answer 43

Common cause of recurrent episodes of vertigo triggered by head movement

Answer 44

certain head movements can trigger attacks e.g. turning over in bed - symptoms settle after 20-60s - asymtpomatic between attacks - does not cause hearing loss or tinnitus

Answer 45

- caused by crystals of calcium carbonate called otoconia that become displace into the semicircular canals - MC in posterior semicircular canal - displaced by viral infection, head trauma, ageing or unknown cause - crystals disrupt normal flow of endolymph through the canals, confusing the vestibular system

Answer 46

Used to diagnose BPPV Involved moving patients head in a way that moves endolymph through the semicircular canals and triggers vertigo in patient with BPPV

Answer 47

To treat BPPV - move crystals in the semicircular canal intra position that does not disrupt endolymph flow

Answer 48

can be performed by the patient at home to improve symptoms of BPPV - sit on edge of bed, and lying sideways, from one side to the other, while rotating the head slightly to face the ceiling

Answer 49

Acute, transient and reversible state of confusion, caused by organise causes

Answer 50

1. hyperactive delirium - agitation - delusions - hallucinations - wandering - aggression 2. Hypoactive - lethargy - slowness with everyday tasks - excessive sleeping - inattention

Answer 51

CHIMPS PHONED Constipation Hypoxia Infection Metabolic disturbance Pain Sleeplessness Prescriptions Hypothermia/pyrexia Organ dysfunction (hepatic or renal impairment) Nutrition Environmental changes Drugs (over the counter, illicit, alcohol and smoking)

Answer 52

- abbreviated mental test score - bloods: FBC< LFTs, Calcium, B12, folate, glucose, blood culture - urinalysis - Imaging = CT head, CXR

Answer 53

- identify and treat underlying cause - supportive management in hospital - take steps to prevent future episodes w.g. drugs that predicate delirium, observe them for early signs

Answer 54

irreversible, progressive decline and impairment of more than on aspect of higher brain function (concentration, memory, language, personality, emotion) This occurs without impairment of consciousness

Answer 55

Alzheimer’s. Vascular. Lewy Body

Answer 56

Old age. Depression. Physical health problems e.g. DM, hypothyroid, vitamin deficiencies. delirium

Answer 57

ACE-III screening tool

Answer 58

Attention. Memory. Fluency. Language. Visiospatial.

Answer 59

1. Acetylcholinesterase inhibitors e.g. Donepezil, Rivastigimine, galantamine (mild to moderate dementia) 2. NMDA antagonist e.g. Memantine. (used for contraindications for AChE inhibitors + more severe dementia) 3. RF reduction in vascular dementia is important too

Answer 60

- Progress steadily - amyloid plaques and neurofibrillary tangles - main presentation = memory loss - > 60 yrs old

Answer 61

APP and presenilin genes (PSEN1, PSEN2) - APP on chromosome 21, so increased risk for people with down syndrome alleles of apolipoprotein E4 = not as good at clearing beta plaques

Answer 62

1. Agnosia- can’t recognise things 2. Apraxia can’t do basic motor skills 3. Aphasia speech difficulties Cognitive impairment Agitation and emotional lability Depression and anxiety Sleep cycle disturbance: Motor disturbance: wandering is a typical feature of dementia

Answer 63

Full blood count Urea and electrolytes Liver function tests Inflammatory markers (e.g., CRP and ESR) Thyroid profile Calcium HbA1c B12 and folate MRI - by specialist to exclude structural pathology CT head - brain looks smaller - atrophy in fronto-temporal regions

Answer 64

Functional ability: inability to carry out normal functions Impairment in 2 or more cognitive domains Differentials excluded

Answer 65

Brain biopsy after autopsy

Answer 66

2nd MC RF: MC in males after stroke hypertension presentation: - stepwise progress (period of stability, before acute decline progression) - main affects white matter areas - cognitive impairment = mood distrubances and disorders

Answer 67

> 50 yrs old Presentation: - rapidly progresses, death MC in first 7 yrs - fluctuating cognitive impairment - visual hallucinations - dementia symptoms 12 months before motor symptoms - Parkinson like symptoms Investigation: DaT scan

Answer 68

- Spherical Lewy body alpha-synuclein proteins deposited in the brain (also present in Parkinson’s)

Answer 69

Cognitive impairments secondary to a mental illness e.g. depression/anxiety.

Answer 70

dementia - make up answers pseudo dementia - answer 'don't know' - impairments in excessive functioning and attention

Answer 71

A neurodegenerative disorder characterised by focal degeneration of the frontal and temporal lobes. - MC <65 yrs early onset It is a heterogenous condition with various subtypes e.g., Pick’s disease

Answer 72

- C9ORF72 gene: found on chromosome 9. MC cause - MAPT (microtubule associated protein)- found on chromosome 17 - Granulin precursor(GRN): found on chromosome 17.

Answer 73

Personality and behaviour change: - Disinhibition - Loss of empathy - Apathy - Hyperorality(e.g. dietary changes, attempt to consume non-edible products, eat beyond satiety) - Compulsive behaviour(e.g. cleaning, checking, hoarding)

Answer 74

Language problems: - Effortful speech - Halting speech - Speech sound errors - Speech apraxia - Word-finding difficulty - Surface dyslexia or dysgraphia: mispronouncing difficult words (e.g. yacht)

Answer 75

Diagnosis based on cognitive assessment Imaging: MRI: exclude other pathology; indicates changes in the frontal and temporal lobes Definitive diagnosis = brain biopsy after a person has died

Answer 76

Serotonin reuptake inhibitors (SSRI) = used for difficult behavioural symptoms. Have been shown to decrease disinhibition, anxiety, impulsivity and repetitive behaviours. Atypical anti-psychotics = can help with agitation and behavioural symptoms.

Answer 77

- head injury - cerebrovascular event - infection - neoplasm - degenerative disorders e.g. Pick's disease

Answer 78

"He's not the father I know" Symptoms: Decreased lack of spontaneous activity, Loss of attention, Perseveration Signs: Neglect (right-sided brain lesions typically neglect the left hemispace)

Answer 79

Bloods – B12 levels, TFTs, serology for syphilis and antinuclear antibodies Consider MRI/CT scanning

Answer 80

General supportive care sharing some principles with dementia care

Answer 81

I HATE FALLING - Inflammation (joints) - Hypotension - Arrhythmia - Tremor - Equilibrium (balance issues, drug induced or other causes) - Foot pain - Auditory/Visual impairment - Leg length discrepancy - Lack of conditioning - Illness - Nutrition poor - Gait problems

Answer 82

Blood pressure regulation - anaemia - arrhythmias - COPD - dehydration - infections - diabetes - heart disorders Central processing - delirium - dementia - stroke Gait - arthritis - foot deformities - muscle weakness

Answer 83

- chest pain - palpitations - sweating - no stimulus - arrythmia - low BP - on exertion - while lying down - known PMH or FH

Answer 84

Beta-blockers (bradycardia) Diabetic medications (hypoglycaemia) Antihypertensives (hypotension) Benzodiazepines (sedation) Antibiotics (intercurrent infection)

Answer 85

bedside - lying and standing BP - urine dipstick - ECG - cognitive screening - blood glucose Bloods - urea + electrolytes - LFTs - bone profile Imaging - CXR - CT head - Echo

Answer 86

- Gait = Physiotherapy - Visual problems = Eye test and ensure wears glasses - Hearing difficulties = Remove earwax Hearing assessment - Medications review = Reduce unnecessary medication - Alcohol intake = Alcohol cessation advice Alcohol service referral - Cognitive impairment = Referral to a psychiatric team - Postural hypotension = Review medication, Improve hydration - Continence = Treat or rule out infections Continence assessment - Footwear Ensure good fitting footwear - Environmental hazards Turn on lights Take up rugs

Answer 87

- A drop in systolic BP of 20mmHg or more (with or without symptoms) - A drop to below 90mmHg on standing even if the drop is less than 20mmHg (with or without symptoms) - A drop in diastolic BP of 10mmHg with symptoms (although clinically much less significant than a drop in systolic BP).

Answer 88

- dehydration - medication - Parkinsons - diabetes - Addisons

Answer 89

- lying and standing BP - tilt testing - ECG - echo

Answer 90

hypersensitive baroreceptors in carotid - cause syncope when pressure put on carotid

Answer 91

State of increased vulnerability resulting from ageing-associated decline in functional reserve, Across multiple physiological systems, Resulting in compromised ability to cope with everyday or acute stressors

Answer 92

- gait speed - self-reported health status - PRISMA-7 questionnaire

Answer 93

Age-related changed: reduced total bladder capacity, reduced bladder contractile function, reduced ability to postpone voiding, atrophy of vagina and urethra, loss of pelvic floor and urethral sphincter musculature, hypertrophy of prostate Comorbidity: reduced mobility, medication, constipation, impaired cognition Reversible: UTI, delirium, drugs, constipation, polyuria, urethral irritability, prolapse, bladder stones and tumours Environmental: Bed Bound, Toilet Too Far/Hard To Access

Answer 94

- Symptoms (stress, urgency, obstructive), bladder diary - Examination: vaginal, rectal, neuro - Urinalysis and midstream urine

Answer 95

Depends on cause Urge - bladder retraining - overactive bladder (anticholinergic) > oxybuytnin or mirabegnon Stress - pelvic floor exercises - duloxetine BPH - finasteride or tamsulosin

Answer 96

- symptoms of urinary retention - obstructed outflow - deteriorating renal function - acute renal failure - intensive care

Answer 97

- blockage - bypassing - infection

Answer 98

- MC faecal impaction or neurogenic - haemorrhoids - rectal prolapse - tumours - IND - drugs

Answer 99

- Treat constipation - Neurological: toilet at appropriate time, planned evacuation (loperamide) - Overflow incontinence: rehydrate, enema (phosphate agent), complete colonic washout, manual evacuation, laxatives - Prevention: once or twice weekly enema

Answer 100

- advanced age - inactivity - low calorie intake - low fibre diet - medications - female

Answer 101

- infrequent bowel motions (<3 per week), - difficultly passing bowel motions, - tenesmus (frequent urge to go to the loo without being able to go) - excessive straining - abdominal distension, - abdominal mass felt at the left or right lower quadrants (stool), - rectal bleeding, - anal fissures, - haemorrhoids, - presence of hard stool or impaction on digital rectal examination

Answer 102

- Dietary e.g. inadequate fibre intake, inadequate fluid intake - Behavioural e.g. inactivity, avoidance of defecation - Electrolyte disturbance e.g. hypercalcaemia - Drugs, particularly opiates, calcium channel blockers and some antipsychotics - Neurological disorders e.g. spinal cord lesions, Parkinson's disease, diabetic neuropathy - Endocrine disorders e.g. hypothyroidism - Colon disease e.g. stricture, malignancy - Anal disease e.g. anal fissure, proctitis

Answer 103

Depends on cause - lifestyle, - laxatives * Bulk = ispaghula husk, methylcellulose, * Stool softeners = docusate sodium, * Osmotic laxative = lactulose, macrogol, * Stimulant laxatives = senna, bisacodyl

Answer 104

Osteoporosis is a condition where there is a reduction in the density of the bones. Osteopenia refers to a less severe reduction in bone density than osteoporosis. Reduced bone density makes bone less strong and more prone to fractures.

Answer 105

SHATTERED S - Steroid use (can increase cortisol = ⬆️ bone resorption + osteoblast apoptosis) H- Hyperthyroidism, hyperparathyroidism (⬆bone turnover) A- Alcohol and tobacco use (poisons osteoblasts) T- Thin = not exercising/using skeleton enough T- Testosterone decrease E- early menopause- oestrogen is protective R- renal or liver failure E- Erosive/inflammatory bone disease D- dietary e.g., reduced Ca2+, malabsorption, diabetes

Answer 106

Reduced bone strength + fall = fracture reduced bone strength caused by: - reduced bone mineral density - reduced bone quality (reduced bone turnover + architecture)

Answer 107

Oestrogen deficiency leads to an increased rate of bone loss. It is key to the activity of bone cell receptors found on osteoblasts, osteocytes, and osteoclasts. It is thought that osteoclasts survive longer in the absence of oestrogen and there is an arrest of osteoblastic synthetic architecture resorption > formation

Answer 108

- They cause an increased turnover of bone. - Prolonged use can result in reduced turnover state however the synthesis is affected resulting in bone mass reduction

Answer 109

Decrease in trabecular thickness, more pronounced for non load-bearing horizontal trabeculae Decrease in connections between horizontal trabeculae (falls put more strain on vertical so preserve vertical connections more) Decrease in trabecular strength and increased susceptibility to fracture

Answer 110

There is an increased frequency of fractures. The most common ones include, vertebral crush fracture, and those of the distal wrist (Colles’ fracture) and proximal femur

Answer 111

It gives a prediction of the risk of a fragility fracture over the next 10 years It involves the inputting of information such as age, BMI, co-morbidities, smoking, family history and if done you can enter a bone mineral score from a DEXA scan

Answer 112

It gives the result as a percentage probability of a: - Major osteoporotic fracture - Hip fracture

Answer 113

It stands for dual-energy x-ray absorptiometry. - low radiation dose It assess how much radiation is absorbed by the bones indicating how dense the bone is. - measures important fracture sites The measurement is usually taken from the Hip (lumbar spine, proximal femur + distal radius MC)

Answer 114

T-score: represents the number of standard deviations compared with the mean for a healthy young adult Z-score: represents the number of standard deviations the bone density falls below a person for their age T-score is more relevant

Answer 115

More than -1 = Normal -1 to -2.5 = Osteopenia Less than -2.5 = Osteoporosis Less than -2.5 plus a fracture = Severe Osteoporosis

Answer 116

Low risk- reassure Medium risk- offer DEXA scan and recalculate the risk with the results High risk: offer treatment

Answer 117

- Activty and exercise - Weight control - Reduce alcohol/stop smoking - calcium supplementation with vitamin D = in patients at risk of fragility fractures with an inadequate intake of calcium.

Answer 118

Bisphosphonates - they interfere with osteoclast activity reducing their activity E.g. Alendronate 70mg once weekly Riseronate 35mg once weekly Zoledronic acid 5 mg once yearly (intravenous)

Answer 119

Reflux and oesophageal erosions. They are taken 30 minutes before food to prevent this Osteonecrosis of the jaw and external auditory canal

Answer 120

Low risk patients should have a follow up within 5 years Patients being treated should have a repeat FRAX and DEXA after 3-5 years and a treatment holiday if BMD has improved (this is 18months to 3 years of treatment before a repeat assessment)

Answer 121

State in which a deficiency of energy, protein, and/or other nutrients causes measurable adverse effects on the body’s form, composition, function and clinical outcome.

Answer 122

1. Acute malnutrition: a brief period of inadequate nutrition that is most commonly in relation to an acute illness with a high inflammatory state, such as pneumonia, and results in muscle wasting and rapid weight loss. 2. Chronic malnutrition: inadequate nutrition that lasts longer than three months. Often secondary to social, behavioural, and economic factors in addition to illness-related causes.

Answer 123

- Decreased nutrient intake (starvation), - Increased nutrient requirements (sepsis or injury), - Inability to utilise ingested nutrients (malabsorption)

Answer 124

- chronic illnesses, - the elderly - living in supported accommodation - drinking excessive amounts of alcohol over a prolonged period. - Being hospitalised for extended periods of time - Problems with dentition, taste or smell - Polypharmacy - Social isolation and loneliness - Mental health issues including grief, anxiety and depression - Cognitive issues including confusion

Answer 125

- BMI <18.5 kg/m2 - unintentional weight loss >10% last 3-6 months - BMI <20kg/m2 AND unintentional weight loss >5% within 3-6mths

Answer 126

- High susceptibility or long durations of infections - Slow or poor wound healing - Altered vital signs including bradycardia, hypotension, and hypothermia - Depleted subcutaneous fat stores - Low skeletal muscle mass

Answer 127

Metabolic disturbances as a result of reintroduction of nutrition to patients who are starved/severely malnourished

Answer 128

- hypophosphataemia - hypokalaemia - thiamine deficiency - abnormal glucose metabolism

Answer 129

- Impaired immunity (increased risk of infections) - Poor wound healing - Growth restriction in children - Unintentional weight loss, specifically the loss of muscle mass - Multi-organ failure - cardiac failure - Death

Answer 130

- Monitor blood biochemistry, - Commence re-feeding with guidelines , - Recognise electrolytes (phosphate, K+, Mg), - Monitor glucose and Na levels, - Supportive care, - Refer to nutritional support team/dietician

Answer 131

- Malnourishment, - Incontinence, - Lack of mobility, - Pain (leads to a reduction in mobility)

Answer 132

Water low score: includes a number of factors including body mass index, nutritional status, skin type, mobility and continence

Answer 133

Barrier creams Pressure redistribution Repositioning Regular skin assessment

Answer 134

Moist wound environment encourages ulcer healing: - Hydrocolloid dressings and hydrogels - Surgical debridement - antibiotics only if there are signs of infection

Answer 135

Grade 1 – non-blanching erythema with intact skin Grade 2 – partial thickness skin loss involving epidermis, dermis or both (abrasion/blister) Grade 3 – full-thickness skin loss involving damage/necrosis of sub-cut tissue Grade 4 – extensive loss, destruction/necrosis of muscle, bone or support structures Unstageable – depth unknown, base of ulcer covered by debris

Answer 136

When a patient has 4+ medications

Answer 137

Suggests medications that may provide additional benefits i.e., proton pump inhibitors for gastroprotection in patients on medications increasing bleeding risk

Answer 138

Used to assess which drugs can be potentially discontinued in elderly patients undergoing polypharmacy

Answer 139

Ability to understand the information relevant to the decision, Retain the information , Weigh up the information, Communicate the decision

Answer 140

- Assume capacity – person assumed to have capacity until proven otherwise - Maximise decision-making capacity – all practical support to help a person make a decision should be given - Freedom to make seemingly unwise decisions - Best interests – all decisions taken on behalf of the person must be in their best interests - Least restrictive option – when making a decision on another person’s behalf, the alternative that achieves the necessary goal and interferes the least with the person’s rights and freedom of action must be chosen

Answer 141

occurs when a person does not consent to care or treatment, for example, a person with dementia who is not free to leave a care home and lacks capacity to consent to this

Answer 142

A document which a person can nominate someone else to make certain decision on their behalf (for example on finances, health and personal welfare) when they are unable to do so themselves. To be valid, it needs to be registered with the Office of the Public Guardian

Answer 143

support and represent people who lack capacity and they do not have anyone else to represent them in decisions about changes in long-term accommodation or serious medical treatment. They can also be present for decisions regarding care reviews or adult protection.

Answer 144

Consider: - Whether the person is likely to regain capacity and can the decision wait - How to encourage and optimise the participation of the person in the decision - The past and present wishes, feelings, beliefs, values of the person and any other relevant factors - Views of other relevant people

Answer 145

- Used to authorise or request specific procedures and refuse treatment in a predefined future situation (advance directive) - Advance refusals of treatment are legally binding if: The person is an adult, Was competent and fully informed when making the decision, The decision is clearly applicable to current circumstances, and There is no reason to believe that they have since changed their mind

Answer 146

- low energy trauma e.g. a full from standing height - pathological fractures e.g. tumour or infection - reduced bone mineral density = osteopenia and osteoporosis

Answer 147

Garden Classification (classifies fractures according to the degree of displacement as seen on x-ray) Stage I: incomplete fracture line or impacted fracture Stage II: complete fracture line, non-displaced Stage III: complete fracture line, partial displacement Stage IV: complete fracture line, complete displacement

Answer 148

classifies fractures according to the angle of the fracture line from horizontal: Type I: between 0 and 30 degrees Type II: between 30 and 50 degrees Type III: more than 50 degrees

Answer 149

- Age (≥65 years in women and ≥75 years in men) - History and risk factors of osteoporosis including menopause, amenorrhoea, smoking, excessive alcohol or caffeine intake, physical inactivity, long-term or high-dose corticosteroid use - Previous fragility fracture - History of falls - Poor nutrition - Low body mass index (<18.5kg/m2) - Dementia - Visual impairment: which increases the risk of falls and subsequently fractures - History of tumours (primary or secondary bone tumours, breast, bowel, prostate, kidney, lung, thyroid tumours)

Answer 150

- Pain: in the hip, groin or knee - Unable to weight-bear - Decreased or painful mobility of the affected hip - The affected leg is shortened, externally rotated and abducted - Palpation of the hip produces pain - The patient is unable to perform a straight leg raise (useful for discerning occult hip fractures) - Pain on gentle internal and external rotation of the affected leg (log roll test) - Soft tissue symptoms: bruising and swelling in and around the hip area

Answer 151

- Alternative fractures such as pubic ramus fractures, acetabular fractures, femoral head and femoral shaft fractures - Slipped capital femoral epiphysis (intermittent pain for months, pain worsens on activity) - Dislocated hip - Femoral head avascular necrosis - Tendonitis of any of the muscles of the hip - Hip bursitis - Osteomyelitis (fever, chills, and swelling or redness in the area)

Answer 152

Investigate for underlying cause - bloods - urinalysis - creatinine kinase = rhabdomyolysis 1. X-ray - 1st line 2. MRI - gold standard to exclude a hip fracture

Answer 153

1. analgesia - IV access for fluid resuscitation, blood transfusion, meds 2. Surgery - urgent reduction and internal fixation followed by early mobilisation

Answer 154

- surgical siet infection - post-op delirium - fat embolism - bleeding - nerve and vessel injury - muscle and ligament damage - leg-length discrepancies - soft tissue irritation

Answer 155

Fracture displacement Non-union or mal union Avascular necrosis of femoral head Venous thromboembolism Pressure sores Infection: pneumonia and urinary tract infections Death

Answer 156

- ageing - prolonged exposure to cold temperatures - chronic illness e.g. diabetes, arthritis, heart conditions - homeless

Answer 157

- irregular heartbeat - kidney failure - confusion - loss of consciousness - liver damage - bleeding disorders - breakdown of muscle tissue

Answer 158

- Be gentle = jarring movements may trigger cardiac arrest - move the person to a warm, dry location - change to dry, warm clothes - cover in blankets - monitor breathing - give warm beverage - don't apply direct heat

Answer 159

DNA damage (mutation to p53 gene) from exposure to UV radiation or other damaging agents trigger abnormal changes in the squamous cells

Answer 160

- scaly red patches - open sores - rough, thickened or wart like skin - raised growths with a central depression can occur in the genitals too

Answer 161

1. cutaneous - top layer of skin 2. metastatic - spread to other parts of the body

Answer 162

- examination - skin biopsy - imaging test - CT or MRI

Answer 163

stage 0: cancer is only in epidermis (SCC in situ) Stage 1: cancer is in the top and middle layers of skin (epidermis and dermis) Stage 2: cancer is in the top + middle layers of skin and moves to target your nerves or deeper layers of skin (epidermis, dermis and subcutis) Stage 3: cancer has spread beyond your skin to your lymph nodes Stage 4: cancer has spread to other parts of your body

Answer 164

- cream: imiquimod or 5-flurouracil - cryosurgery = freeze cancer cells - photodynamic therapy (PDT) = blue light to remove cancer cells - curettage and electrodesiccation - excision - systemic chemo