gerries new Flashcards
What is Benign paroxysmal positional vertigo
MC cause of vertigo
sudden onset of dizziness and vertigo triggered by changes in head position
inner ear problem
What are features of Benign paroxysmal positional vertigo
vertigo triggered by change in head position (e.g. rolling over in bed or gazing upwards)
may be associated with nausea
Symptoms settle after around 20 – 60 seconds
positive Dix-Hallpike manoeuvre
What is Dix-Hallpike manoeuvre
rapidly lower the patient to the supine position with an extended neck
a positive test recreates the symptoms of benign paroxysmal positional vertigo
rotatory nystagmus towards the affected ear
How is Symptomatic relief given for Benign paroxysmal positional vertigo
Epley manoeuvre (successful in around 80% of cases)
teaching the patient exercises they can do themselves at home, termed vestibular rehabilitation, for example Brandt-Daroff exercises
what causes BPPV
caused by crystals of calcium carbonate called otoconia that become displaced into the semicircular canals
What is MC location of BPPV
posterior semicircular canal.
What can displace crystals of calcium carbonate in ear
viral infection, head trauma, ageing or without a clear cause.
what does peripheral cause of veritgo mean
the problem is located in the inner ear rather than the brain.
What is the Epley manoeuvr
move the crystals in the semicircular canal into a position that does not disrupt endolymph flow.
What is recurrence rate of BBPV
half will have recurrence 3-5 years after their diagnosis
WHat age group has highest risk of falls
over the age of 65 have the highest risk of falling with 30% of those over 65 and 50% of those over 80 falling at least once a year
What medical conditions could contribute to fall
Stroke
MS
Parkinson’s disease
Infection
Vasovagal syncope
Arrhythmias
Diabetes
Anaemia
pneumonia
Chronic pain
What medication can cause fall
Beta-blockers (bradycardia)
Diabetic medications (hypoglycaemia)
Antihypertensives (hypotension)
Benzodiazepines (sedation)
Antibiotics (intercurrent infection)
WHat can falls lead to
fractures, particularly hip fractures, which have high rates of disability and death
How can fall be investigated
- orthostatic blood pressure measurements to detect postural hypotension
- ECG for cardiac arrhythmias
- Imaging studies if fracture or intracranial injury is suspected
- Cranial nerve examination
- Medication Review
What are types of Non-Accidental Falls
Syncope-related Falls:
Gait/Balance-related Falls:
Muscle Weakness-related Falls:
How is Functional Ability Assessed
Timed Up and Go test (TUG) or Berg Balance Scale (BBS)
What is included in a full falls risk assessment.
Gait
Visual problems
Hearing difficulties
Medications review
Alcohol intake
Cognitive impairment
Postural hypotension
Continence
Footwear
Environmental hazards
WHat is Frailty
multidimensional syndrome, is characterised by diminished strength, endurance and physiological function
What are two types of Frailty
physical frailty and frailty phenotype
What si physical frailty
weight loss, exhaustion, low physical activity, slowness and weakness
what is frailty phenotype
includes cognitive and social aspects
What are clinical implications of frailty
higher risk of adverse health outcomes such as falls, delirium, disability and hospitalisation
What is the significant implications of Frailty on treatment
altered pharmacokinetics and pharmacodynamics
How is frailty assessed
Fried Frailty Index or Groningen Frailty Indicator
How is frailty managed
multi-component interventions including exercise, nutrition optimisation and medication review
What is Osteoporosis
severe reduction in bone mineral density and defects in bone tissue micro-architecture.
What is the T Score at the Hip of Osteopenia
-1 to -2.5
what can cause secondary Osteoporosis
Hyperthyroidism
Hyperparathyroidism
Alcohol abuse
Immobilisation
How is Tscore measured
femoral neck, measured on a DEXA scan
What are two type of primary Osteoporosis
- Postmenopausal osteoporosis (type I)
- age-related osteoporosis (type II)
what is Osteopenia
less severe decrease in bone density
why do post-menopausal women experience increased degradation of bone tissue
decreased levels of oestrogen
What is the T Score at the Hip of Osteoporosis
Less than -2.5
What is the T Score at the Hip of severe Osteoporosis
Less than -2.5 plus a fracture
What is Z-score
the number of standard deviations the patient is from the average for their age, sex and ethnicity
What are RF for Osteoporosis
Older age
Post-menopausal women
Reduced mobility and activity
Low BMI (under 19 kg/m2)
Low calcium or vitamin D intake
Alcohol and smoking
Personal or family history of fractures
What is T-score
number of standard deviations the patient is from an average healthy young adult.
Is T score or Z score used to make diagnosis of Osteoporosis
T score
What chronic diseases are RF for osteoprosis
Chronic diseases (e.g., chronic kidney disease, hyperthyroidism and rheumatoid arthritis)
Where does Tamoxifen block oestrogen receptors
blocks oestrogen receptors in breast tissue but stimulates oestrogen receptors in the uterus and bones
helps prevent osteoporosis
What medications are RF for osteoporosis
Long-term Glucocorticoids (e.g., 7.5mg or more of prednisolone daily for longer than 3 months)
Certain medications (e.g., SSRIs, PPIs, anti-epileptics and anti-oestrogens)
What are the most common pathological fractures seen in osteoporosis
Vertebral compression fractures
Neck of femur
Colles fractures (fall on an outstretched arm)
What investigations ca exclude any secondary causes of osteoporosis
Quantitative CT and US of the heel
History and physical examination
FBC
U&Es (serum calcium, creatinine, phosphate)
LFTs (ALP, transaminases)
TFTs
25-OH vit D & 1,25-OH vit D
Serum testosterone & prolactin
Lateral radiographs of lumbar and thoracic spine
Protein immunoelectrophoresis and urinary Bence-Jones protein
What selective oestrogen receptor modulator (SERM) is used to treat osteoporosis
Raloxifene
stimulates oestrogen receptors in the bone but not in the uterus or breast.
How is 10-year risk of a major osteoporotic fracture and a hip fracture calculated
FRAX tool
What clinical risk factors are in FRAX
Age (between 40 and 90 years)
Gender
Previous fracture
Parent fractured hip
Smoking
Glucocorticoids (more than 3 months at a dose of prednisolone 5mg daily)
Rheumatoid arthritis
Secondary osteoporosis
Alcohol consumption
BMD
What are DDx for osteoporosis
Osteomalacia
Paget disease of bone
myeloma, primary and metastatic bone tumours, lymphoma
What is the initial management for osteoporosis
Lifestyle modification for the prevention of osteoporotic fractures
- Falls risk assessment
- Weight-bearing and muscle strengthening exercises
- Calcium (at least 1000mg)
- Vitamin D (400-800 IU)
- Calculation of 10-year probability of osteoporotic fragility fracture
What is the first-line pharmacological treatment for osteoporosis
Bisphosphonates
What is insufficient intake of calcium
less than 700mg per day
How do Bisphosphonates work
inhibit osteoclast-mediated bone resorption
What are SE of Bisphosphonates
Reflux and oesophageal erosions
Atypical fractures (e.g., atypical femoral fractures)
Osteonecrosis of the jaw (regular dental checkups are recommended before and during treatment)
Osteonecrosis of the external auditory canal
How is oral Bisphosphonates taken
empty stomach with a full glass of water
patient should sit upright for 30 minutes before moving or eating
WHat are examples of Bisphosphonates
Alendronate 70 mg once weekly (oral)
Risedronate 35 mg once weekly (oral)
Zoledronic acid 5 mg once yearly (intravenous)
What is an alternative treatment option is bisphosphonates are not suitable
- Denosumab (a monoclonal antibody that targets osteoclasts)
- Romosozumab (a monoclonal antibody that targets sclerostin – a protein in osteocytes that inhibits bone formation)
- Teriparatide (acts as parathyroid hormone)
- Hormone replacement therapy (particularly in women with early menopause)
- Raloxifene (a selective oestrogen receptor modulator)
- Strontium ranelate (a similar element to calcium that stimulates osteoblasts and blocks osteoclasts)
What does Raloxifene increase risk of
venous thromboembolism.
What is a pathological fracture
when a bone breaks due to an abnormality within the bone
what are ways to describe how a bone breaks
- Transverse
- Oblique
- Spiral
- Segmental
- Comminuted (breaking into multiple fragments)
- Compression fractures (affecting the vertebrae in the spine)
- Greenstick
- Buckle (torus)
- Salter-Harris (growth plate fracture)
What classification can be used to describe fractures of the lateral malleolus (distal fibula).
Weber classification
What is Weber classification
Type A – below the ankle joint – will leave the syndesmosis intact
Type B – at the level of the ankle joint – the syndesmosis will be intact or partially torn
Type C – above the ankle joint – the syndesmosis will be disrupted
What cancers metastasise to the bone
Po – Prostate
R – Renal
Ta – Thyroid
B – Breast
Le – Lung
PoRTaBLe
How are fractures imaged
X-rays - 1st line
CT scans -> if xray inconclusive
How is mechanical alignment of the fracture achieved
Closed reduction via manipulation of the limb
Open reduction via surgery
How is relative stability provided to fracture
External casts (e.g., plaster cast)
K wires
Intramedullary wires
Intramedullary nails
Screws
Plate and screws
What are possible early complications of fracture
Damage to local structures (e.g., tendons, muscles, arteries, nerves, skin and lung)
Haemorrhage leading to shock and potentially death
Compartment syndrome
Fat embolism (see below)
Venous thromboembolism (DVTs and PEs) due to immobility
What are possible long term complications of fracture
Delayed union (slow healing)
Malunion (misaligned healing)
Non-union (failure to heal)
Avascular necrosis (death of the bone)
Infection (osteomyelitis)
Joint instability
Joint stiffness
Contractures (tightening of the soft tissues)
Arthritis
Chronic pain
Complex regional pain syndrome
How does fat embolisation present
respiratory distress, altered mental status, and petechial rash
What is Cardiac failure
clinical syndrome that results from structural or functional cardiac disorders impairing the ability of the ventricle to fill with or eject blood
How is Cardiac failure categorized
systolic and diastolic failure
What is Systolic failure
reduced ejection fraction, results from the heart’s diminished capacity to pump blood effectively.
WHat is diastolic failure
impaired filling of the heart chambers due to increased stiffness.
WHat are common causes of heart failure
Ischaemic heart disease
Valvular heart disease (commonly aortic stenosis)
Hypertension
Arrhythmias (commonly atrial fibrillation)
Cardiomyopathy
What are the symptoms of cardiac failure
Breathlessness
Cough
Orthopnoea
Paroxysmal nocturnal dyspnoea
Peripheral oedema
Fatigue
triad of symptoms: dyspnoea, fatigue, and fluid retention
What are the signs of cardiac failure
- Tachycardia (raised heart rate)
- Tachypnoea (raised respiratory rate)
- Hypertension
- Murmurs on auscultation indicating valvular heart disease
- 3rd heart sound on auscultation
- Bilateral basal crackles (sounding “wet”) on auscultation of the lungs, indicating pulmonary oedema
- Raised jugular venous pressure (JVP)
- Peripheral oedema of the ankles, legs and sacrum
How is cardiac failure diagnosed
Clinical assessment (history and examination)
N-terminal pro-B-type natriuretic peptide (NT‑proBNP) blood test
ECG
Echocardiogram
Bloods for anaemia, renal function, thyroid function, liver function, lipids and diabetes
Chest x-ray and lung function tests to exclude lung pathology
What classification system grades the severity of symptoms related to heart failure
New York Heart Association (NYHA)
What is the New York Heart Association (NYHA) classification system
Class I: No limitation on activity
Class II: Comfortable at rest but symptomatic with ordinary activities
Class III: Comfortable at rest but symptomatic with less than ordinary activity
Class IV: Symptomatic at rest
What are the five principles of cardiac failure management
R – Refer to cardiology
A – Advise them about the condition
M – Medical treatment
P – Procedural or surgical interventions
S – Specialist heart failure MDT input, such as the heart failure specialist nurses, for advice and support
RAMPS
What does the urgency of the referral and specialist assessment for cardiac failure depend on
NT-proBNP
If a patient has a NT-proBNP of 1000ng/litre how soon should they be seen and have echocardiogram
From 400 – 2000 ng/litre should be seen and have an echocardiogram within 6 weeks
Above 2000 ng/litre should be seen and have an echocardiogram within 2 weeks
What is the first-line medical treatment for chronic heart failure
A – ACE inhibitor (e.g., ramipril) titrated as high as tolerated
B – Beta blocker (e.g., bisoprolol) titrated as high as tolerated
A – Aldosterone antagonist when symptoms are not controlled with A and B (e.g., spironolactone or eplerenone)
L – Loop diuretics (e.g., furosemide or bumetanide)
WHen should ACE inhibitors be avoided and what is alternative
patients with valvular heart disease
alt = angiotensin receptor blocker (ARB) (e.g., candesartan)
What should be closely monitored whilst taking diuretics, ACE inhibitors and aldosterone antagonists.
U&Es & Renal fucntion
can cause electrolyte disturbances.
can cause hyperkalaemia
When is Aldosterone antagonists used in cardiac failure
second-line treatment
when there is a reduced ejection fraction and symptoms are not controlled with an ACEi and beta blocker.
What Surgical procedures can be used in cardiac failure
Implantable cardioverter defibrillators
Cardiac resynchronisation therapy (CRT)
heart transplant
What is B-type natriuretic peptide
hormone produced mainly by the left ventricular myocardium in response to strain
What are causes of Constipation
Functional constipation
Medication-induced constipation
Irritable bowel syndrome with constipation (IBS-C)
Colorectal cancer
Hypothyroidism
What is functional constipation
MC form
infrequent bowel movements, hard stools, and difficulty passing stool
lack of fibre in the diet, inadequate fluid intake, or a sedentary lifestyle.
What are complications of constipation
overflow diarrhoea
acute urinary retention
haemorrhoids
What symptoms are associated with constipation
Infrequent bowel movements (fewer than three per week)
Hard or lumpy stools
Difficulty in passing stools (straining)
Sensation of incomplete evacuation after a bowel movement
Bloating and abdominal discomfort
What complications are related to chronic constipation
haemorrhoids, anal fissures, rectal prolapse or faecal impaction.
what is Encopresis
faecal incontinence
sign of chronic constipation
rectum stretched and looses sensation
Large hard stools remain in the rectum and only loose stools are able to bypass the blockage and leak out, causing soiling.
What lifestyle factors can contribute to the development and continuation of constipation:
Habitually not opening the bowels
Low fibre diet
Poor fluid intake and dehydration
Sedentary lifestyle
Psychosocial problems such as a difficult home or school environment (always keep safeguarding in mind)
What is the management for constipation
- exclude any faecal impaction
- advice on lifestyle measures
- first-line laxative: bulk-forming laxative first-line, such as ispaghula
- second-line: osmotic laxative, such as a macrogol
What are ‘alarm’ symptoms for constipation
sudden onset constipation in older adults, blood in stools, unexplained weight loss, abdominal pain and change in stool calibre.
Name two medications that can cause constipation
Opioids
CCB
What are Risk factors for Urinary incontinence
advancing age
previous pregnancy and childbirth
high body mass index
hysterectomy
family history
What are Classification of urinary incontinence
overactive bladder (OAB)/urge incontinence
stress incontinence:
mixed incontinence:
overflow incontinence:
What is overactive bladder (OAB)/urge incontinence
due to detrusor overactivity
What is stress incontinence
leaking small amounts when coughing or laughing
what is mixed incontinence
both urge and stress
what is overflow incontinence
due to bladder outlet obstruction, e.g. due to prostate enlargement
What are initial investigation for Urinary incontinence
- bladder diaries should be completed for a minimum of 3 days
- vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
- urine dipstick and culture
- urodynamic studies
How is urge predominant incontinence managed
- bladder retraining - gradually increase the intervals between voiding)
- bladder stabilising drugs: Anticholinergic (antimuscrinic) medication, for example, oxybutynin, tolterodine and solifenacin
- mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
How is stress predominant incontinence managed
- pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
- duloxetine
- surgical procedures: e.g. retropubic mid-urethral tape procedures
What can cause Overflow Incontinence
anticholinergic medications
fibroids
pelvic tumours
and neurological conditions such as multiple sclerosis, diabetic neuropathy and spinal cord injuries.
WHat is Undernutrition
manifests as stunting, wasting, and deficiencies of micro- and macronutrients
WHat is Overnutrition
results in overweight or obesity due to excessive nutrient intakes
what is Protein-energy malnutrition
severe form of undernutrition characterised by insufficient intake of protein and energy.
what can Protein-energy malnutrition lead to
marasmus, presenting as significant weight loss or kwashiorkor with oedema and skin changes.
What can Overnutrition increase risk of
type 2 diabetes mellitus, cardiovascular disease, hypertension and certain cancers
WHat biochemical abnormalities can Malnourished patients have
anaemia, hypoalbuminaemia or electrolyte imbalances.
what causes malnutrition
Inadequate amounts of nutrients (e.g. poor variety in diet)
Difficulty absorbing nutrients (e.g. gastrointestinal dysfunction such as coeliac disease)
Increased nutritional demands (e.g. post-surgery for healing)
what is Malnutrition
sudden or chronic decrease in the intake of sufficient nutrition to support the body’s requirements for growth, healing, and maintenance of life.
Name a standardised screening tool for Malnutrition
Malnutrition Universal Screening Tool (MUST), the Malnutrition Screening Tool (MST) and Mini-Nutrition Assessment (MNA)
What are RF for Malnutrition
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
What are clinical features of malnutrition include
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
what are complications of malnutrition
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
Death
WHat is Hyperthermia
elevated core body temperature exceeding the body’s thermoregulatory set-point due to failed thermoregulation, is often induced by heat stroke or adverse drug reactions
What can untreated Hyperthermia lead to
multi-organ dysfunction
What is Hypothermia
when the body loses heat faster than it can produce, causing a dangerously low body temperature.
What usually causes Hypothermia
prolonged exposure to cold weather or immersion in cold water.
What can untreated Hypothermia lead to
esult in arrhythmias, impaired consciousness and potentially fatal complications like hypotensive shock.
What are four criteria a patient needs to meet to demonstrate capacity to make a decision
Understand the decision
Retain the information long enough to make the decision
Weigh up the pros and cons
Communicate their decision
WHat is Lasting power of attorney (LPA)
a person legally nominates a person of their choice to make decisions on their behalf if they lose capacity in the future
property and financial and health
what is Deprivation of liberty safeguards (DoLS)
an application made by a hospital or care home for patients who lack capacity to allow them to provide care and treatment.
What are 4 types of consent form
Consent Form 1: Patient consenting to a procedure
Consent Form 2: Parental consent on behalf of a child
Consent Form 3: Where the patient won’t have their consciousness impaired (e.g., a breast biopsy)
Consent Form 4: Where the patient lacks capacity
What is Mental Capacity Act:
used in patients who require treatment for physical disorders that affect brain function. Remember this may be delirium secondary to sepsis or a primary brain disorder such as dementia
What are 3 types of consent
- Informed
- Expressed
- Implied
What is a Do Not Attempt Cardiopulmonary Resuscitation order (DNACPR)
document that formalises decision-making about whether an individual should be treated with CPR, in the event of a cardiac arrest.
advance directive
Where do Pressure sores commonly occur
typically occur over bony prominences such as sacrum, coccyx, heels or hips
What are Pressure sores
localised injuries to the skin and underlying tissue due to prolonged pressure
What is the pathophysiology of pressure sores
ischaemic damage due to compression of capillaries leading to cell death and ulceration
What is stage 1 pressure sores
characterised by non-blanchable erythema without skin loss
What is stage 4 pressure sores
full thickness skin loss with extensive destruction involving muscle, bone or supporting structures
What is stage 3 pressure sores
full thickness skin loss extending into subcutaneous tissue but not through underlying fascia
What is stage 2 pressure sores
partial thickness skin loss affecting epidermis or dermis
WHat are RF for pressure sores
immobility, malnutrition, incontinence and sensory impairment
What is risk assessment tool for estimating an individual patient’s risk of developing a pressure ulcer
Waterlow Score
What are Complications of Pressure Sores
Infection
Sepsis
Necrotising fasciitis
How can pressure ulcers be prevented
individual risk assessments, regular repositioning, special inflating mattresses, regular skin checks and protective dressings and creams
What is the management of Squamous cell carcinoma of the skin
- Surgical excision with 4mm margins if lesion <20mm in diameter.
- If tumour >20mm then margins should be 6mm.
- Mohs micrographic surgery may be used in high-risk patients and in cosmetically important sites.
What are complications of Squamous cell carcinoma of the skin
Local recurrence
Metastasis
Nerve involvement
Morbidity from surgical treatment - deficits
What are Rf for Squamous cell carcinoma of the skin
- excessive exposure to sunlight / psoralen UVA therapy
- actinic keratoses and Bowen’s disease
- immunosuppression e.g. following renal transplant, HIV
- smoking
- long-standing leg ulcers (Marjolin’s ulcer)
- genetic conditions e.g. xeroderma pigmentosum, oculocutaneous albinism
What is the Stage-specific 5-year survival rate of Localised SCC
99%
What is the Stage-specific 5-year survival rate of Regional SCC
63%
What is the Stage-specific 5-year survival rate of Distant metastasis SCC
16%
What are indicators of a good prognosis for SSC
Well differentiated tumours
<20mm diameter
<2mm deep
No associated diseases
What are indicators of a poor prognosis for SSC
Poorly differentiated tumours
>20mm in diameter
>4mm deep
Immunosupression for whatever reason
Perineural invasion
